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STATE OF CALIFORNIA QOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> CALIFORNIA ACCIDENTAL REWSE PREVENTION i <br /> PROGRAM REGISTRATION <br /> OES 2735.6(NEW 6/97) PAGE---/ OF / <br /> REGISTRATION TYPE UPDATETYPE <br /> Read instructions on reverse before completing. J ❑ NEW EJ-OPDATE ❑ ADD ❑ DELETE D REVISE <br /> I. Business Owner/Operator Information <br /> BUSINESS NAME <br /> A�jeM/n/6?Dx-) IRF-SN .lA,)C� <br /> ADDRESS (NumberWd Stmf) <br /> 3s Soy w 9 W�s> F� �� <br /> clry <br /> COUNfY STATE ZIP CODE <br /> STaC,r=-,raAJ e.-J�- 9s2✓sA/S e1g. I 9sais- <br /> PHONE NUMBER <br /> OWNER/OPERATOR NAME <br /> d69- '7b'3 - 9?-06 <br /> II. Regulated Substance List <br /> Process Max. CAS# <br /> A. Name of Each Regulated Substance quantity(Ibs) <br /> t. AIII D,c'6 us /9&7A4aAJia C sao :T664-4/-�L <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> Percent Process Max. CAS# <br /> B. Name of Each Regulated Substance in a Mixture Weight Quantity(Ibs) <br /> 1. <br /> 2. <br /> III. Certification <br /> I, the owner or operator of the aforementioned business, hereby certify that the registration information provided <br /> above is true, accurate, and complete to the best of my knowledge, based upon reasonable inquiry. I am fully aware <br /> that this certification,executed on the date indicated below, is made under penalty of perjury under the laws of the <br /> State of California. <br /> OWNERIOPERATOR NAME(PRINT) <br /> DATE EXECUTED <br /> OWNER/OPERATOR SIG TUR /Q <br /> ,to <br />