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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 /> Please type or print legibly in ink. <br /> NEW NUMBER REQUESTS Check all that apply. <br /> It 1 . 1 am applying for a new permanent California ID number as a hazardous waste : ❑ Generator ❑ Transporter <br /> Reason for a new number: A. W 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 . [ 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 /> GL / r)/' /� C' <br /> 6 . Site/Facility/Business Name ( Include DBA) : Wei 6 I;/ A5 )1S A t1flo P 4 jr <br /> 7 . Site Location : 5Y' / Y . Gran k7 <br /> � A)Kxhoil 4 of5209V <br /> City State Zip Code County <br /> 8 . (a ) Federal Employer ID Number ( b ) Board of Equalization Fee Account Number <br /> ( (b) is only required from generators of greater than 5 tons per calendar year.) <br /> 9 . Mailing Address : 14loA �� 5 <br /> st3Voc t©n G14 <br /> City State Zip Code <br /> 10 . Site Contact Person : A,:, <br /> 'First'Name Last Name <br /> Contact Person Address : ). 5303 e / A 0 AIr <br /> .S eet <br /> � foil GAW g6e7� ay <br /> City f /�% State Zip Code <br /> Contact Person Phone Number: � �i) q]/ 6' 570 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) : L� (r /1 n R /, <br /> Owner Address : !� y �tl � am(�/� Srxr\yh L,� qsZO <br /> City State Zip Code <br /> Owner Phone Number <br /> tree�) ,y �� � ��� Fax Number: ( ) <br /> Area Code's Phone Number Area Code Fax Number <br /> 12 . Standard Industrial Classification (SIC) C e for the Site : _ (4 -Digit Number) <br /> 13 . Certification : / certify under penalty o0a At the information on this document was prepared to the best of my knowledge and <br /> belief to be true, accurate and com Tete <br /> SIGNATURE (handwritten ) Date " ! r / q <br /> Name (print) Title �� � 1%J Phone <br /> q - Gf � � � 04v5e? <br /> DTSC Form 1358 (09/18 ) <br /> Page 3 of 3 <br />