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State of California—California Environmental Protection Agency Department of Toxic Substances Control -HWMP P.O.Box 806,Sacramento,CA 95612-0806 PERMANENT STATE ID NUMBER APPLICATION Please type or neatly print in ink. Please review the line-by-line instructions carefully. To check on the status of your request,go to www.hwts.dtsc.ca.gov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) ❑ 1. 1 am applying for a new permanent California ID number as a hazardous waste: ❑ Generator ❑ Transporter Reason for new number: A. ❑ Never had a number B. ❑ Business moved C. ❑ Legal owner of business changed If your business generates greater than 100 kg of RCRA hazardous waste other than those hazardous waste fisted in 40 CFR 261.5 subparts(c)and(d),per month, complete Form 8700-12 for an EPA(federal)ID number. CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER (See instructions.) For existing ID number: C A 0 0 0 0 3 7 9 9 ❑ 2. 1 am updating the mailing address and/or contact information only. ❑ 3. 1 am inactivating this ID number. ■❑ 4. 1 am reactivating this ID Number. ❑ 5. 1 am changing the business name only, no ownership change. (See instructions.) 6. Site/Facility/Business Name(Include DBA): CitV of Lathrop-Louise Avenue Water Treatment Facilit 7. Site Location: 2112 East Louise Avenue Street Lathrop California 95330 San Joaquin City State Zip County 8. (a)Federal Employer ID Number 68-0195186 (b)Board of Equalization Fee Account Number b is only required from generators of greater than 5 tons per calendar ear. (See instructions.) 9. Mailing Address: 390 Towne Centre Drive Street Lathrop California 95330 City State Zip (See instructions.) 10. Site Contact Person: Milt Daley First Name Last Name Contact Person Address: 390 Towne Centre Drive Street Lathrop California 95330 City State Zip Contact Person Phone Number: (209)941-7430 Fax Number: (209) 941-7339 Area Code Phone Number Area Code Fax Number Contact Person Business Email Address: and le ci.lathro .ca.us Preferred Primary Communication: W Mail ❑■ Email (See instructions.) 11. Legal Business Owner(not property owner): CitV of Lathrop First Name Last Name owner Address: 390 Towne Centre Drive Street Lathrop California 95330 City State Zip Owner Phone Number: (209)941-7430 Fax Number: (209 )941-7339 Area Code Phone Number Area Code Fax Number (See instructions.) 12. Standard Industrial Classification(SIC)Code for the Site: 8 9 9 9 (4-Digit Number) (See instructions.) 13. Certification: /certify under penalty of law that the information on this document was prepared to the best of my knowledge and belief to be,true, accurate and complete. SIGNATURE ;z&& &- DATE NAME(print) 1 � G. l c TITLE ri Sr t� PHONE 2t7Cj '71-Z -tX7Y DTSC 1358(5129/15)