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Contra Costa County Health Services Department <br /> Contra Costa County Certified Unified Program Agency <br /> r Hazardous Materials Programs <br /> California Accidental Release Prevention Program <br /> REGULATED SUBSTANCES REGISTRATION <br /> STATIONARY SOURCE INFORMATION <br /> Stationary Source Name: _J( Facility ID# U.S.EPA ID# Phone: <br /> Stationary Source Address:2City: Zip Code: <br /> 6q J µ�a 4dE FCA <br /> Latitude: Longitude: Dun&Bradstreet: SIC: No.of Emp: <br /> Owner/Operator: Phone: <br /> r�rc 6:,t Z c f 430 -3Y qq <br /> Mailing Address: City: State: Zip Code: <br /> y� 7 <br /> Name of Parent Company: Dun&Bradstreet: Phone: <br /> IFFT <br /> Person Responsible for RMP: Title: Phone: <br /> Emergency Contact: / Title: /' Phone: 24 Hour Phone: <br /> irEG'/ G2 v/ �ivn l/[ l M S/o-�3��J� %0 -�7? <br /> Is the Stationary Source Subject to Tine 8 CCR)r5189(Process Safety Management)? Is the Stationary Source Subject to Pjan 355 of Title 40 of CFA7 <br /> cy7 es 11 No Yes 11 No <br /> Is the Stationary Source Required to Have as CAA Tide V Permit? Last Safety Inspection: <br /> r' Yes 11 No Agency <br /> Date <br /> Regulated Substances/Flammable Mixture at Stationary Source: Quantity of Regulated Substance Distance From Largest Single <br /> in Largest Single Container Container to Public Receptor: <br /> (Ibs.): <br /> 2. 2. 2. <br /> 3. 3. 3. <br /> 4. 4. 4. <br /> 5. 5. 5. <br /> 6. 6. 6. <br /> 7. 7. 7. <br /> 8. 8. 8. <br /> Signature of ner perator: Printed Name: Date: <br />