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12/08.195 09,E UST CLEANUP FUND 4 912094640135 IVU.O4o wee <br /> VENDOR DATA RECORD • Ls 9S' 49 oz <br /> t (Requfred In lieu of IRS W-3 W"rn doing business With the State of California) <br /> STD.Pe REV&SE, <br /> kt <br /> State of Cafitornia PURPOSE: Informationcord8inedinthis tor <br /> PLEASE Water Resources Control Elcard will be used by State agencies to prepare into <br /> RefuRrt DIVISION OF CLEAN WATER PROGRAMS mationRetums(ForntIe9 and for withholUin <br /> ro; CLEANUP FUNS UNIT on <br /> payments to nonresident vendors, <br /> 2014 T Street-P.O, Box 844212 <br /> i _ Sacramento, CA 94244-2120 (See Privacy Statement❑n reverse.) <br /> Vp1pORg 9e$lNESS NAME <br /> OWNERS NLL NINE:jE.L (at) <br /> STREET AOpgEs3 ' <br /> ARE YOU$UE]EOTTO WOERN,aACIU <br /> WMMLDMOT <br /> CITY,$TATE,AML$IPCODE r�.. N'o rr b IAS F..Lx$J <br /> INSTRUCTIONS: Cheek box indicatingt ❑ Y£S ❑ Np , <br /> type of business entity and provide taxpayer iden[ificanon number. <br /> (2). Check box indicating resident or nonresident. (See reverse for sdWifonat information). <br /> �!+g(3). Check one or more VENDOR ACTIVITY boxes specifying vendor activhy type <br /> �RsstDEN�M-ATL <br /> CORPORATION MEpCAL 9ERVIGE$(lnPludrig denn.ay„ <br /> (Enbr FerlerNEmP6y✓benWiyAen Number) ❑ fq;ASydroU.npy,e0rgri.iy, ❑ SER VMES(NONMEOrCAM <br /> d,rrPe-+cit.rel <br /> 1 O EWPMENTISUPP4E3 <br /> ❑ Resident-Qualified to do business in CA! rtremEr(rom,LaM wlAnEtdnsl <br /> Permanent place of business in CA ❑ RENr <br /> ❑ Non Reside- (See Reverse) �'} OTNER <br /> INDIVIDUAVSOLEPROPRIETOR NON EMPLOYEE COMPEN$ANON Jmc,,dm$ ❑ FQU1PMENTrSUPPIcS <br /> (For"Sepal Sep:.hr Ac_y,mr AL:mp,rENr Nor F4wi ❑ repiri undm.inlen.ne,,EEnaryEcron,ekf _ (Eiempr hom 4�.,r,,•,;Af0�t1 <br /> ❑ MEDICAlsEavlcss(A,r:n,d„gd.nn.ey. <br /> r-r,nr.w,en.Ln«APV MLameey. <br /> II--II diiroviceb..rs/ . <br /> Resident ❑ Non Resident(See Reverse) ❑ INTEREST(Frw,.arGem srr.wmnasEy <br /> PARTNEnSHIP <br /> (f AM1•Fd,.al Fn.,aory rwnvr,deon NErPEyrJ RENT <br /> i t I i I 1 i ROYALTIES <br /> ❑ Residenl ❑ Non Resident(See Reverse) ❑ PR MS AND AWARDS <br /> I=STATE pR TRUST O <br /> lEaer FeaWlf&rgkrer aenG!'orten lvum6wJ OTMER(5'e.nry) <br /> I —L—Jf <br /> Resident(Estate Decedent was a CA resident$1 <br /> the time of death <br /> ❑ 9esfdent (Trust)-At least one trustee le a CA <br /> resident e <br /> ❑ Non Reskient(See Reverse) <br /> !hore6y certify under p <br /> resldenMalty of per/ury that the Information provided art this document is true and correct. <br /> !f m c status should change,i wfil om it inform cu. <br /> vTNOR�p VENppR REPAesENTATIVE'S NAME(rrn aPdnp "TLC <br /> GNATURE <br /> �9 DATE " TELAPRONE NUMDER <br /> MTRACTIAEASE NUMBER <br /> NONEMPLOYEEMEDICAL (NI-44NDNRESDENi WintNOLDING <br /> COMPENSATION ❑ SEAVUES ❑ REM❑ OTNEq <br /> 'pRTABLE INCpME CODE PAS$fAtEAOMkETRATIVEMAMYAL$ESTIDPAtan Che a.) rNITMLS <br /> T ❑2 3 fu7E WITULED STANDARD RATE <br /> 4 125 EJO L7 EJ WAIVED <br /> LJ ❑ REDUCED R4 TE—% <br />