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3TATE�)F CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> ;ALIFORNIA ACCIDENTAL RELEASE PREVENTION <br /> PROGRAM REGISTRATION <br /> OES 2735.6(NEW 6197) PAGE 1 OF 1 <br /> REGISTRATION TYPEUPDATE TYPE <br /> Read instructions on reverse before completing. NEW UPDATE ADD D DELETE REVISE <br /> I. Business Owner/Operator1nformation <br /> BUSINESS NAME <br /> Northern California Youth Center <br /> ADDRESS (Number and Street) <br /> 7650 S. Newcastle Road <br /> CITY COUNTY STATE ZIP CODE <br /> Stockton San Joaquin CA 95215 <br /> OWNERIOPERATOR NAME PHONE NUMBER <br /> Tim Sutherland, Business Manager (209) 944-6327 <br /> II. Regulated Substance List <br /> Process Max. <br /> A. Name of Each Regulated Substance Quant;t„(Ibs) CAS# <br /> 1. Not Applicable <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> B. Name of Each Regulated Substance in a Mixture Percent Process Max. CAS# <br /> 9 Weight Quantity(ibs) <br /> 1 Chlorophacinone (Ground Squirrel Bait) .005% .01 3691-35-8 <br /> 2 Cyclohexlamine (WC 410 Boiler Return Line Treatment) 107. 160.20 108-91-8 <br /> Ill. 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 /> that this certification, executed on the date indicated below, is made under penalty of perjury under the laws of the <br /> State of California. <br /> OWNER/OPERATOR NAME(PRINT) <br /> Tim Sutherland, Business Manager <br /> OWNERIOPERA OR SIGNA E DATE EXECUTED <br /> 9y�3— <br />