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EPA ID NUMBER MAILING ADDRESS, IF DIFFERFNT: COMPANY NAME (DBA) STREET CITY STATE _ ZIP - COUNTRY roar compl.l< ,f int USA) CONTACT PERSON PHONE NUMBER(_) (F,m N..) (Lw N..) fit. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE: Use either one or nvo SIC codes (a four digit number) that best desntbe Your company's products, servtces, or Industrial aotvtn Example: 7384 Photohnirhine fah 3672 Printed circuit boards First: qliLq Second: TV. PRIOR PERAfIT STATUS: Check yins or no to each question: YES NO ❑ I. Did you file a PBR Nonce of Intent to Operate (DTSC Form 8362) in 1992 for this location? ❑ 2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or interim status for any of these treatment units? ❑ 3. Do you now have or have you ever held a state or federal full permit or interim status for any other hazardous waste activities at this location? ❑ 4. Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you �y ase now ooafyLng for at this location? ❑ }� 5. Hu this location ever been Inspected by the state or any local agency as a hazardous waste generator? V. /PRIOR ENFORCEMENT HISTORY: Not required from generatora only nor6ing as conditionally exempt. YES NO ❑ Within the last three years, his this facility been the subject of any convictions, judgments, settlements, or final orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health enforcement agency? (For the purposes of this form, a notice of violation does not constitute an order and need not be reported unless it was not corrected and became a linal order.) ClIf you answered Yes, check this box and attach a listing of convictions,judgments, seulemenu, or orders and a copy of the cover sheet from each document. (See the Instructions for more information) DTSC 1772 (1 t93) Pate 2