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AtE OF CAI,IFQRNIA `r 7, -,� � GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> 'CALIFORNIA ACCIDENTAL REL REVFNTION—,t' ' <br /> GROGRAM REGISTRATION <br /> :S 2735.6(NEW 6197) f OCT -' 2 199 PAGE __L OF ` <br /> ,rte- R I TRAnoN TYPE UPDATE TYPE <br /> Z� instructions on reverse before co�pleting- -.- - - NEW' ❑ UPDATE I d ADD F-1 DELETE 1:1 SiEVISE <br /> Business Owner/Operator Inforrrta n <br /> cUSINE55 NAME <br /> ;DORESS (NumberandStrearJ <br /> -3I7y ` I COUNTY STA T EE ZIP CODE <br /> 3 --- -- Prn1 t► u; C 9 S 3 7 to <br /> CWNEPJOPERATOR NAMPHONE NUMBER <br /> 1. Regulated Substance List <br /> Process Max. ! <br /> A. Name of Each Regulated Substance Quantity (Ibs) i CAS# <br /> i Cin oc;rJ�Z_ <br /> _ a <br /> 1' <br /> . <br /> B. Name of Each Substance in a Mixture Regulated I Percent I Process Max. CAS# <br /> 9 I Weight ! Quantity(Ibs) <br /> I <br /> k <br /> Ill. 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 fully aware <br /> ti- itis certification, e_recuted on the date indicated below, is made under penalty of perjury under the laws of the <br /> Std of California. <br /> OWNER70PERATORNAME,PRINT] I I <br /> OWNEP/OPERATOR SIGNATURE �J 'DATE EXECUTED <br />