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I .. State of California — California Environmental Protection Agency Department of Toxic Substances Control D. Exports. If you intend to export, please refer to the requirements found in 22 CCR sections 66273.20 (small quantity handler), 66273.40 (large quantity handler), and/or 66273.90 (CRT material handler). Please specify the name of the facility that will export material(s) you have received and the type of materials intended for export. Facility That Will Export Material Materials Exported (Check all that apply) 1: Name Address Street Country Phone L__) City State Zip Phone U Mailing Address Street City State Zip EPA ID number (if applicable) 2: Name Address Street Country Mailing Address Street Phone (—) City State Zip Phone �) City State Zip EPA ID number (if applicable) E. Certification ❑ Bare CRTs ❑ CRT Devices ❑ CRT Glass ❑ UWEDs ❑ Universal Waste Batteries ❑ Universal Waste Lamps ❑ Exempt Circuit Boards ❑ Other Scrap Metal ❑ Bare CRTs ❑ CRT Devices ❑ CRT Glass ❑ UWEDs ❑ Universal Waste Batteries ❑ Universal Waste Lamps ❑ Exempt Circuit Boards ❑ Other Scrap Metal ❑ I certify under penalty of law that the facility, named in Section A, accepts, but does not treat or recycle, any universal waste electronic devices and/or CRT materials. The information contained in this notification is true, correct and complete to the best of my knowledge. Signature Printed Name Title Date F. Notifications must be submitted to DTSC by certified mail, return receipt requested. MAIL TO: Department of Toxic Substances Control Hazardous Waste Management Program Regulatory Program Development Division P.O. BOX 806 Sacramento, CA 95812-0806 Attention: UWED/ CRT Materials Handling Activities DTSC 1382 (11115104) Page 3 of 3