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srAr>:Or CAL Faaw <br /> VENDOR DATA RECORD <br /> (Required In lieu of IRS W-9 when doing business with the State of California) <br /> sm.m+(MV.SAM <br /> OSP wrwFNrc PURPOSE: information contained in this form <br /> POSE _ will be used by State agencies to prepare Infor. <br /> RETURN <br /> STET Ei AooREss mation Rehr Form 1099 and fo: <br /> TO: on payments to nonresident vends.:. <br /> cm,s:ATE zwccoE (See Privacy Statement on raver,..;., <br /> YO+OGi'SBUsiME33ti1WE OWWEFL9Ti1LLf,w1E fLmCF,rLA�l1 � ~""•�•.:. •• <br /> Inland Paint Company + ��— <br /> STREE7ADDRESS - ARE YOU SLIMCT70z!:W:," ,; - <br /> 117 West Harding Way 1AATHHOLDIMIT <br /> CITY.STATE,AND ZfP COLE Isom irrUck."OW M :... - .. <br /> Stockton, CA 95204 ❑ YES ❑ <br /> INSTRUCTIONS. (1). Check box indicating type of business entity and provide taxpayer identification number. ~- <br /> (2). Check box indicating resident or nonresident. (See reverse for additional information). <br /> (3). Check one or more VENDOR ACTIVITY boxes specifying vendor activity type. <br /> Y VF31DOFrTYPE)AE5t1ENCYSTATUS k a y V1�! <br /> .. --. -':.i..r... .n, <br /> ❑ CORPORATION ❑ MEDICAL SERv1cE4I&K*0r:gd«*,r1 ❑ SFFIVICESI>yON1. <br /> (EMAW Pedrai Erobrw k"ft fa amrt Ak—bwj pour-ay pffrzl- =V.gvlorn�: <br /> okar�.tr . <br /> � ❑ Eouwfakom <br /> pFimnge farm Se,h <br /> ❑ Resident-Qualified to da business in CA <br /> Permanent place of business in CA ❑ RENT <br /> Nan Resident (See Reverse) ! ❑ °� _ � _ <br /> ISPm�fit <br /> ❑ INOMDUALISOLE PROPRIETOR ❑ NON EmptO'EECOLIPEMUMN(hitdud-,q ❑ Eau1PU9?ffMUPFyI. <br /> tF>�1,�Saaaf sraaiy 4ewwse lrVrnBrr ► HOTFEIV) M"M and inrarrwrcm,a,nmuedry.fr:) (E+.awBoer <br /> Semi—MEDICAL SERv10ESf*=k.*pdowsay <br /> ❑ Resident ❑ kon Resident (See Reverse) ❑ 'CREST rF.m:W jz&,SU" <br /> ❑ PARTNERSHIP <br /> fF--P-dnal Elnpb�'r o.,n:o:on Afu.,a-rJ ❑ REIN - <br /> ! ❑ ROYALTIES <br /> ❑ Resident ❑ Non Resident (See Reverse) ❑ PROSSAND AWARDS _ <br /> ESTATE OR TRUST <br /> TErw F"WW Erphrar Ak"wbff) ❑ OTHER opeotrf <br /> ❑ Resident (Estate) -Decedent was a CA resident at <br /> the time of death <br /> ❑ Resident (frust)-At least one trustee is a CA _ <br /> resident <br /> ❑ Non Resident (See Reverse) <br /> I hereby certify under penalty of perjury that the information provided on this document is true and correct _w <br /> If my rsslden status should change,I wlA romp(ly Inform you. <br /> AUTHORCED VENDOR REMMIXERTATNE'S riAHE - <br /> . (riPm er Pr'"q ml.f <br /> DATE - TELEPHONE MLXQEA <br /> n— <br /> .. x-n...v., ., <br /> _.- <br /> CbkTRAGTIL£ASE NUfdBER `•«. ...,>- t3#')l ':frSJw;k7t�tt:. - -- •^�""' <br /> ❑ NONEMPLOYEEYEDIGL fk*hJ MONRESIDENTWM44OLDI <br /> COURAT' <br /> -•. .. <br /> PE�TICM ❑ s avlc s ❑ ILEfrr ❑ OTHER ❑ <br /> ADLIMISTRATf1rE STANDARD RAT <br /> ❑RE ERTABU;E3ME CODE PEA STATE YAefkIAL SECTION sriz 1f R.a�A pp.) 1MiTLALS .. <br /> t ❑ 2 ❑ 3 ❑ ❑ $ ❑ 5 ❑ 7 DATE wTTfu cin ❑ WAIVED <br /> ❑ REDUCED RATE_% <br />