AUTHORIZATION FORM
This is to certify that I,
*
of
*
authorize
of
to conduct business with the Department of Toxic Substances Control on my and/or company's behalf.
Check any that apply.
*
Complete and sign the Permanent State ID Number Application for the purpose of obtaining, reactivating, inactivating or updating an EPA ID number.
Complete the electronic Verification Questionnaire (eVQ).
Site/Facility/Business Name:
*
If incorporated or a LLC, include business name and DBA
Federal Employer Identification Number (FEIN):
*
Site Location:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Signature (handwritten)
*
Title:
*
Date:
*
-
Month
-
Day
Year
Date
Rev. 11/21/2018
Submit
Should be Empty: