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STATE OF CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> CALIFORNIA ACCID EN AL43ELS, I RFVENTION <br /> PROGRAM REGISTRATION <br /> OES 2735.6(NEW 6197) PAGE QF <br /> before <br /> R GISTRATION TYPE UPDATE TYPE <br /> 1 'ins&uctions on reverse beforecompleting. NEW ❑ UPDATE ❑ App ❑ 08-= ❑ REVISE <br /> 1. Business Owner/Operator1-6formation <br /> BUSINESS NAME <br /> w <br /> ADDRESS (NumbersndS 1 <br /> i <br /> 1 <br /> CITY CO _ STATE ZI CODE <br /> E-1- tit CrT 9.._ <br /> OWNER/OPERATOR NAME PHONE NumSER <br /> 11. Regulated Substance List <br /> Process Max. <br /> A. Name of Each Regulated Substance Quantity(lbs) CAS# <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 7. <br /> S. <br /> B. Name of Each Regulated Substance in a Mixture Percent Process Max. CAS# <br /> Weight Quantity(lbs) <br /> / fT- A <br /> IN �4- A AJ <br /> 2. <br /> Ill. Certification <br /> 1, 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 /> tl his certification, executed on the date indicated below, is made under penalty of perjury under the laws of the <br /> Stu e of California. <br /> OWNERIOPERATOR NAkAE(PRINT} <br /> OWNERfDPERATOR^aIGNATLIRE DATE EXECUTED <br /> �J <br />