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State of California California Environmental Protection Agency <br /> PERMANENT STATE ID NUMBER APPLICATION Department of Toxic Substances Control <br /> DTSC Form 1358 (Revision 12/2021) Page 1 of 2 <br /> IMPORTANT: Please read the instructions before completing this form. Fill out this form <br /> completely and accurately. Incomplete and inaccurate forms will be rejected. All fields <br /> are required except those indicated as optional. <br /> NEW NUMBER REQUESTS. Check all that apply <br /> ❑✓ 1. 1 am applying for a new permanent State ID number as a hazardous waste: <br /> ❑✓ a) Generator ❑ b) Transporter <br /> Reason for a new number: <br /> ❑✓ a) Never had a number ❑ b) Business moved ❑ c) Legal business owner changed <br /> i <br /> CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER <br /> For existing ID number (include the lettered prefix): <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. <br /> ❑ 5. 1 am changing the business name only, no ownership change. <br /> 6. a) Site/Facility/Business Name (include DBA): DIAMOND GAS AND FOOD MART <br /> b) Business Type: ❑Sole Proprietor ❑✓ Corpor tnership ❑LLC ❑Other <br /> 7. Site Location: 824 E YOSEMITE AVE <br /> MANTEtX CA 95336 SAN JOAQUIN <br /> City State ZIP Code County <br /> 8. a) Federal Employer ID Number (FEIN): 82-3778402 <br /> b) CA Secretary of State Filing/Entity Number (if applicable): <br /> c) CDTFA Account Number (if applicable): <br /> 9. Mailing Address:824 E YOSEMITE AVE <br /> MANTECA Street CA 95336 <br /> City State ZIP Code <br />