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,-ATE OF CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> ,ALIFORNIA ACCIDENTAL RELEASE--PREVEWMN <br /> 3ROGRAM REGISTRATION-, <br /> }ES 2735.6(NEW 6/97) PAGE OF <br /> � � O PAREGSSTRATIDN TYPE �IJPOATETYPE. <br /> ?P--1 instructions on reverse before completing. NEW UPDATE ADD 0 DELETE '[:] REVWSE <br /> . business OwnerlOperator t formation <br /> 3USIN 5 NAME q <br /> �� <br /> ADDRESS (NumberanbSfreef) ' <br /> COUNTY �' ST TE �ZIP CODE <br /> PHONE NUMBER <br /> OWNEAIOPERATOR NAME ,.+ <br /> II. Regulated Substance List <br /> Process Max. ICAS# <br /> A. Name of Each Regulated Substance Quantity (Ibs) <br /> a, <br /> 3. <br /> 6 <br /> /. <br /> i5. <br /> Percent Process Max. CAS# <br /> B. Name of Each Regulated Substance in a Mixture weight Quantity (lbs) <br /> I. <br /> k <br /> i <br /> 7 <br /> III. Certification <br /> 1, the owner or operator of the aforementioned business, hereby certify that the registration information provided <br /> above is true, accurate, and complete to the best of my knowledge, based upon reasonable inquiry. I am filly aware <br /> that this certification, executed on the date indicated below, is made under penalty of perjury hinder the laws of the <br /> S„.._ of California. <br /> OWNERICPERATOR NAME(PRINT) <br /> OWNERIO RATOR SIGN -R I DATE ECUTED <br />