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STATE OF CALIF019NIA <br /> CALIFORNIA ACCIDENTAL.RELEASE- jPN GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> PROGRAM REGISTRATIONS i! <br /> QES 2735.6(NEW 6197) <br /> i �f} PAGE OF <br /> U�j T <br /> REGISTRATION TYPE UPDATE TYPE <br /> ' <br /> instructions On reverse before'cnrnp ehn . r NEW ❑ UPDATE a ADO E DELETE � REVISE <br /> I. Business Owner/Operator Information <br /> BUSINESS NAME <br /> FR L-- L67 —IZc �T2�'GKIh-ice, sic, <br /> ADDRESS tNumberandSbeet) <br /> '510C 1,Ii.'. iz <br /> CITY COUNTf STATE ZIP CODE <br /> Lcp� S4ti JOAQV INCA ct5Z�2— <br /> OWNERlOPERATOR NAME PHONE NUMBER <br /> II. Regulated Substance List <br /> A. Name of Each Regulated Substance Process MaQuantity(Ibsx.) CAS# <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> b�- <br /> 7. <br /> 8. I <br /> B. Name of Each Regulated Substance in a Mixture Percent Process Max. ' CAS# <br /> ,�j Weight Quantity(lbs) <br /> 1. LI CU'D r� PAS Cr rS PRoF'A1tiG S7-5 — IVDU 7 "'9S-(c <br /> �ep'o its- 0-1- 0j <br /> 2. <br /> III. Certification <br /> I, 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 fully aware <br /> th 'tis certification, executed on the date indicated below, is made under penalty of perjury under the laws of the <br /> StSeof California. <br /> SWIA yOPERATOR NAME(PATNT7 - - - - - - <br /> 3E-r-zNlot F-rte N) OU65^0A <br /> OWNERJOPERATOR SIGNATURE DATE EXECUTED <br /> to ",;a,oeh'- ct'30-97 <br />