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State of California — California Environmental Protection Agency Department of Toxic Substances Control <br />Notice of Intent to Handle <br />Universal Waste Electronic Devices (UWEDs) and/or Cathode Ray Tube (CRT) Materials <br />— — IMPORTANT NOTE — — 1 <br />I <br />Do not complete this notification if you are a handler who will: <br />- dismantle or disassemble electronic devices into their components (wires, UW <br />batteries, UW lamps, plastics, metals, etc.); <br />- process electronic devices and/or their components by shredding, grinding, sawing, <br />cutting, etc.; <br />- remove yokes from CRTs and vent CRTs without breaking CRT glass; or <br />- process CRT materials by breaking CRT glass, <br />Instead, complete and submit DTSC Form 1388 "Notice of Intent to Handle and Treat or Recycle". <br />A. Handler Information [22 CCR sections 66273.13/.33(d)(2)(A)(1) — (7) and 66273.82(x)(1) - (7)]. Please fill in <br />the information requested below. <br />Handler (Facility) Name <br />Physical Address <br />Street City County State Zip <br />Mailing Address <br />Street City County State Zip <br />Contact Person (Name/Title) <br />Mailing Address <br />Facility Owner <br />Mailing Address <br />E -Mail address <br />Street <br />Street <br />City <br />City <br />Phone �) <br />County State <br />Phone (—) <br />County State <br />(if available) <br />EPA ID Number (if applicable) <br />M <br />Zip <br />B. Proposed Handling Activities [22 CCR sections 66273.13/.33(d)(2)(A)(8) — (9) and 66273.82(x)(8) - (9)]. <br />Please check the box(es) that describes the source(s) of the materials you will collect. Please check the <br />box(es) that describes the types of materials you will collect. Check all applicable boxes. <br />Materials Accepted From: <br />DTSC 1382 (11/15/04) <br />— — — — — — — — <br />Materials to Be Handled ' <br />(Check all that apply) <br />❑ Cathode Ray Tube Materials <br />❑ Universal Waste Electronic Devices <br />❑ Universal Waste Batteries 1 <br />❑ Universal Waste Lamps <br />❑ Exempt Circuit Boards <br />❑ Other Scrap Metal <br />—Page 1 of 3 <br />Businesses <br />❑ <br />Households <br />❑ <br />Other collectors <br />❑ <br />Other please specify <br />DTSC 1382 (11/15/04) <br />— — — — — — — — <br />Materials to Be Handled ' <br />(Check all that apply) <br />❑ Cathode Ray Tube Materials <br />❑ Universal Waste Electronic Devices <br />❑ Universal Waste Batteries 1 <br />❑ Universal Waste Lamps <br />❑ Exempt Circuit Boards <br />❑ Other Scrap Metal <br />—Page 1 of 3 <br />