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E State of California — California Environmental Protection Agency 2: Name Phone (�) Address Street City State Zip Country Phone C___j Mailing Address Street City State Zip Country EPA ID number 3: Name Address (if applicable) Phone l—) Street City State Zip Country Phone �) Mailing Address Street City State Zip Country EPA ID number (if applicable) E Department of Toxic Substances Control ❑ 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 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 handier). 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 1: Name Address Street Country Mailing Address Street EPA ID number Phone �) City State Zip Phone C__j City State _ (if applicable) sm 2: Name Phone C_) Address Street City State Zip Country Phone �) Mailing Address Street City State Zip EPA ID number (if applicable) Materials Exported (Check all that apply) ❑ 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 DTSC 1388 (11/15/04) Page 2 of 5