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State of California — California Environmental Protection Agency Department of Toxic Substances Control Notice of Intent to Handle and Treat or Recycle Universal Waste Electronic Devices (UWEDs) and/or Cathode Ray Tube (CRT) Materials A. Handler Information 122 CCR sections 66273.1303(d)(2)(A)(1) — (7) and 66273.82(a)(1) - (7)]. Please fill in the information requested below. Handler (Facility) Name Businesses Phone �) Households Physical Address Government agencies ❑ Other collectors Street City County State Zip Mailing Address Street City County State Zip Contact Person (Name/Title) Phone L Mailing Address Street City County State Zip Facility Owner Phone �) Mailing Address Street City County State Zip E -Mail address (if available) EPA ID Number (if applicable) B. Proposed Handling Activities [22 CCR sections 66273.1303(d)(2)(A)(8) — (9) and 66273.82(a)(8) - (9)]. Please check the box(es) that describes the source(s) of the materials you will collect. Please check the box(es) that describes the types of materials you will collect. Check all applicable boxes. Materials Accepted From: ❑ Businesses ❑ Households ❑ Government agencies ❑ Other collectors ❑ Other please specify Materials to Be Handled (Check all that apply) ❑ CRT Materials ❑ UWEDs ❑ Universal Waste Batteries ❑ Universal Waste Lamps ❑ Exempt Circuit Boards ❑ Other Scrap Metal C. Please specify where you intend to send the materials you will receive from offsite sources. If you intend to export materials, please complete Section "D" below. Attach additional sheets if needed. Destination Facility or Handler 1: Name Phone (_) Address Street City State Zip Country Phone �) Mailing Address Street City State Zip Country EPA ID number (if applicable) Materials Shipped (Check all that apply) ❑ Bare CRTs ❑ CRT Devices ❑ CRT Glass ❑ UWEDs ❑ Universal Waste Batteries ❑ Universal Waste Lamps ❑ Exempt Circuit Boards ❑ Other Scrap Metal DTSC 1388 (11116104) Page 1 of 5