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State of California—Califomia Environmental Protection Agency Department of Toxic Substances Control -HWMP P.O.Box 806,Sacramento,CA 95812-0806 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.hvvts.dtsc.ca.gov and click on Reports. NEW NUMBER REQUESTS Check all that apply. (See instructions.) ❑ta 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 listed 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 ❑ 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): City of Lathrop-Louise Avenue Water Treatment Facilit 7. Site Location: 2112 East Louise Avenue Street Lathrop CA 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 Lathrolp CA 95330 City State Zip (See instructions.) 10. Site Contact Person: Milton Dale First Name Last Name Contact Person Address: 390 Towne Centre Drive Street Lathrop CA 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: mdale ci.lath ro .ca.us Preferred Primary Communication: W Mail ❑ Email (See instructions.) 11. Legal Business Owner(not property owner): City of Lathro First Name Last Name Owner Address: 390 Towne Centre Drive Street Lathrop CA 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: I 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 co e SIGNATURE DATE 08/10/2016 NAME(print) Anthony Ouellette TITLE Consultant PHONE 916-670-4070 DTSC 1358(5/29/15)