Laserfiche WebLink
SENDER: I-if UPWAWIMMdim, <br /> ----------------- <br /> epartment of Toxic Substances Control -HWMP <br /> ■ Complete items 1,2,and 3. A Signature P.O.Box 806,Sacramento,CA 95812-0806 <br /> ■ Print your name and address on the reverse X SIGNED BY -O Agent CATION <br /> so that we can return the card to you, n ❑Addressee ions carefully. <br /> ■ Attach this card to the back of the mailplece, B. Received by(Printed l,m ) O. Date of Delivery and click on Re ports. <br /> or on the front if space permits. - (See instructions.) <br /> 1. Article Addresed to: D. <br /> Is delivery ffmk " 11- p Ves-- enerator ❑ Transporter <br /> ryddttemr. <br /> ❑No <br /> ! _ Legal owner of business changed <br /> ©• �Q� _ _ _ - azardous w <br /> 001 ISI. <br /> C �S�e coons.) <br /> ,nn <br /> 3. <br /> ice <br /> 0 Priority Mail <br /> IIIII�I'I�I�II'�I�I�II III�IIIII�II�'�I���I I II 0AAddu¢s8 atureeResnneaoellvery ❑O Ree9 tnaedM li-�WCeo ENVIRONMENTAL HEALTH <br /> ❑CerNed Mail® Delivery PERMIT/$ERVICES <br /> 9590 9403 0867 5183 9644 26 ❑Certified Mall Restricted bellvery ❑Return Rete pt lar <br /> D Collect on Delivery Merchandise <br /> 2. An1Cle Number(Iians(el(romseryTce label) ❑Collect on Delivery Restricted Delivery ❑signature Confrma9onTM lestionnaire B. ❑ Other <br /> ❑Insured Mail ❑Signature Cantinnatlon <br /> Insured Mail Restdcted Delivery Restricted Doi" <br /> (over$500) <br /> PS Fonn 3811,April 2015 PSN 7530.02-D00-9053 Domestic Return Recelpt <br /> r - - / e s. <br /> 6. Site/Facility/Business Name(Include DBA : 5 <br /> 7. Site Location: 5`p '4u• ®� <br /> l"-44A9—;-P <br /> re � c <br /> � i-li1 <br /> City <br /> <br /> qu ati ee u u r <br /> ((b) o q i f ge a or g er h t al r) <br /> (See instructions.) <br /> 9. Mailing Address: _�/ <br /> Street 7'-- �I�p <br /> f45711101-7 <br /> i/5 ,� 1 <br /> city llState /dZipp J <br /> /f� � ,A L (See instructions.) <br /> 10. Site Contact Person: //� !� �/ <br /> irst�N/ams Last Name <br /> Contact Person Address: 'ST <br /> ��O <br /> City State Zip <br /> Contact Person Phone Number. (.11V7 —/401110' 99 Fax Number: W) '06 <br /> Area Code Phone"u��m''b--e__r// ea Code Fax Number <br /> f <br /> Contact Person Business Email Address: Preferred Primary Communication: ail ❑ Email <br /> (See instructions.) <br /> 11. Legal Business Owner(not property owner): O +� <br /> v Name <br /> Owner Address: <br /> Stre city State I <br /> Owner Phone Number: ���`� y6> Fax Number: <br /> Area Code Phone Number •�7 Area Fax Number <br /> 12. Standard Industrial Classification(SIC)Code for the Site: / 5 3 V (4Digft Number) (See instructions.) <br /> 13. Certification: I certify under penalty of law that the information on this document was prepared to the best of my knowledge and <br /> belief to be, true, ac r e and c mplete. <br /> SIGNATURE DATE <br /> _q,/2 <br /> NAME(print) L� TITLE �Ca�Y��- PHONE��/ 7J /� 7 <br /> OTSC Form 1358(01/17) <br />