Laserfiche WebLink
w <br />State of California — California Environmental Protection Agency <br />Department of Toxic Substances Control <br />C. Please specify where you intend to send the materials you will receive from offsite sources. If you intend to <br />export materials, please complete Section "D" below. Attach additional sheets if needed. <br />Destination Facility or Handier <br />1: Name Phone �) <br />Address <br />Street City State Zip <br />Country Phone �) <br />Mailing Address <br />Street City State Zip <br />Country <br />EPA ID number (if applicable) <br />2: Name <br />Address <br />Street <br />Country <br />Mailing Address _ <br />Street <br />Country <br />EPA ID number <br />3: Name <br />Address <br />Street <br />Country <br />Mailing Address _ <br />Street <br />Country <br />EPA ID number <br />DISC 1382 (11115/04) <br />Phone (� <br />City State Zip <br />Phone (_) <br />City State Zip <br />(if applicable) <br />Phone L_) <br />City State <br />Phone �) <br />City State <br />(if applicable) <br />Zip <br />Materials Shipped <br />(Check all that apply) <br />❑ Bare CRTs <br />❑ CRT Devices <br />❑ CRT Glass <br />❑ UWEDs <br />❑ Universal Waste Batteries <br />❑ Universal Waste Lamps <br />❑ Exempt Circuit Boards <br />❑ Other Scrap Metal <br />❑ Bare CRTs <br />❑ CRT Devices <br />❑ CRT Glass <br />❑ UWEDs <br />❑ Universal Waste Batteries <br />❑ Universal Waste Lamps <br />❑ Exempt Circuit Boards <br />❑ Other Scrap Metal <br />❑ Bare CRTs <br />❑ CRT Devices <br />❑ CRT Glass <br />❑ UWEDs <br />❑ Universal Waste Batteries <br />❑ Universal Waste Lamps <br />❑ Exempt Circuit Boards <br />❑ Other Scrap Metal <br />Page 2 of 3 <br />