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°,TATE OF CALIFORNIA -- GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> '.ALIFORNIA ACCIDENTAL RELEA PEEETO[VT. <br /> PROGRAM REGISTRATION <br /> ,ES 2735.6(NEW 6197) 1 {n� <br /> OCT - 7 PAGE; =OF <br /> RE STRATION TYPE UPDATE TYPE <br /> instructions on reverse before cola leting- NEW El UPDATE I I ADD DELETE ❑ REVISE <br /> Business Owner/Operator Infor '"rt <br /> BUSINESS NAME - <br /> ADDRESS (Numtwand5treat) <br /> c. 0 �Uch \ I R �u <br /> CIN COUNTY STATE ZIP CODE <br /> OWNERIOPERATPRNIIIIE PHONE NUMBER <br /> ?I. Regulated Substance List <br /> Process Max. <br /> .A. Name of Each R�eguiated Substance CAS# <br /> ll `` Quantity (Ibs) � <br /> 2. <br /> 3 <br /> i <br /> I <br /> 7 <br /> 8. Name of Each Re uiated Substance in a Mixture Percent Process Max. CAS# <br /> 9 Weight Quantity (Ibs) <br /> I <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 fidly aware <br /> tl his certification, executed on the date indicated below, is made under penalty of perjury under the laws of the <br /> Std of California. <br /> OWNERJOPERATOR NAME(PRINT) <br /> OWNEPJOPERATOR SIGNATURE l DATE EXECUT <br /> 1 <br />