Dtsc Form 1358, Permanent State Id Number Application – California Environmental Protection Agency, Department Of Toxic Substances Control Page 3
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3State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Office of Environmental Information Management
PERMANENT STATE ID NUMBER APPLICATION
Please type or print legibly in ink.
NEW NUMBER REQUESTS
Check all that apply.
□
□
□
1. I am applying for a new permanent California ID number as a hazardous waste:
Generator
Transporter
□
□
□
Reason for a 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, please complete Form 8700-12 for a federal EPA ID number.
CHANGES TO STATUS OR INFORMATION FOR AN EXISTING STATE ID NUMBER
C A
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
For existing ID number:
□
2.
I am updating the mailing address and/or contact information only.
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3.
I am inactivating this ID number.
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4.
.
I am reactivating this ID number. Reason (
):
A
Verification Questionnaire
B.
Other
please select one
□
5.
I am changing the business name only, no ownership change.
6. Site/Facility/Business Name (
): ______________________________________________________________________
Include DBA
7. Site Location: ____________________________________________________________________________________________
Street
____________________________________________________________________________________________
Zip Code
City
State
County
8. (a) Federal Employer ID Number__________________ (b) Board of Equalization Fee Account Number______________________
((b) is only required from generators of greater than 5 tons per calendar year.)
9. Mailing Address: __________________________________________________________________________________________
Street
__________________________________________________________________________________________
Zip Code
City
State
10. Site Contact Person: _____________________________________________________________________________________
First Name
Last Name
Contact Person Address: __________________________________________________________________________________
Street
__________________________________________________________________________________
Zip Code
City
State
Contact Person Phone Number: (_____) ________________________ Fax Number: (_____) ___________________________
Area Code
Phone Number
Area Code
Fax Number
Contact Person Business Email Address:______________________________________________________________________
11. Legal Business Owner
: _____________________________________________________________________
(not property owner)
Name
Owner Address: _________________________________________________________________________________________
Zip Code
Street
City
State
Owner Phone Number: (_____) _____________________ Fax Number: (_____) _____________________________________
Area Code
Phone Number
Area Code
Fax Number
12. Standard Industrial Classification (SIC) Code for the Site:
___ ___ ___ ___
(4-Digit Number)
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 and complete.
SIGNATURE (handwritten) _________________________________________________________ Date ____________________
Name (print) _________________________________ Title ________________________ Phone _______________________
DTSC Form 1358 (09/18)
Page 3 of 3
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