Laserfiche WebLink
State of California — California Environmental Protection Agency Department of Toxic Substances Control <br />Office of Environmental Information Management <br />PERMANENT STATE ID NUMBER APPLICATION <br />mease type or print iegimy legiblyIn ink. <br />NEW NUMBER REQUESTS Check all that apply. <br />❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter <br />Reason for a new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed <br />If your business generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste listed in 40 CFR 261.5 <br />subparts (c) and (d) per month, please complete Form 8700-12 for a federal EPA ID number. <br />CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br />For existing ID number: C A <br />❑ 2. 1 am updating the mailing address and/or contact information only. <br />❑ 3. 1 am inactivating this ID number. <br />❑ 4. 1 am reactivating this ID number. Reason (please select one): A. ❑ Verification Questionnaire B. ❑ Other <br />❑ 5. 1 am changing the business name only, no ownership change. <br />6. Site/Facility/Business Name (Include DBA): <br />7. Site Location: <br />Street <br />City <br />8. (a) Federal Employer ID Number <br />State Zip Code County <br />(b) Board of Equalization Fee Account Number <br />�) is only required from generators of greater than 5 tons per calendar <br />9. Mailing Address: <br />Street <br />City State Zip Code <br />10. Site Contact Person: <br />First Name Last Name <br />Contact Person Address: <br />Street <br />City State Zip Code <br />Contact Person Phone Number: ( ) Fax Number: () <br />Area Code Phone Number Area Code Fax Number <br />Contact Person Business Email Address: <br />11. Legal Business Owner (not property owner): <br />Name <br />Owner Address: <br />Street City State Zip Code <br />Owner Phone Number: () Fax Number: ( ) <br />Area Code Phone Number Area Code Fax Number <br />12. Standard Industrial Classification (SIC) Code for the Site: (4 -Digit Number) <br />13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and <br />belief to be true, accurate and complete. <br />SIGNATURE (handwritten) Date <br />Name (print) <br />DTSC Form 1358 (09/18) <br />Title <br />Phone <br />Page 3 of 3 <br />