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Page 2 of 33 <br /> EPAIDNUMBER CAD 009 212 929 <br /> MAILING ADDRESS,M nrFFPRENT: <br /> COMPANY NAME(DBA) <br /> STREET <br /> STATE_ZIP <br /> CITY <br /> COUNTRY <br /> (only complete if not USA) <br /> PHONE NUMBER —— — <br /> CONTACT PERSON (First Name) (Last Name) <br /> III. TYPE OF COMPANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE: <br /> Use either one or two SIC codes(a four digit number)that best describes your company's products,services or industrial activity. <br /> Example: 7384 Phatofinichine lab <br /> =Printed circuit boards <br /> First:3471 Plating & Polishing Second: <br /> IV. PRIOR PERMIT STATUS: Check yes or no to each question: <br /> YES NO <br /> ® ❑ 1. Did you file a PBR Notice of Intent to Operate(DTSC Form 8462)in 1992 for this location? <br /> ❑ ® 2. Do you now have or have you ever held a state or federal hazardous waste facility full permit or interim <br /> status for any of these treatment units? <br /> ❑ ® 3• Do you now have or have you ever held a state or federal full permit or interim status for any other <br /> hazardous waste activities at this location? <br /> ❑ ® 4, Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you <br /> are now notifying for this location? <br /> ® ❑ 5. Has this location ever been inspected by the state or any local agency as a hazardous waste generator? <br /> V. PRIOR ENFORCEMENT HISTORY: Not required from generators only notifying as conditionally exempt. <br /> YES NO <br /> ® ❑ Within the last three years,has this facility been the subject of any convictions,judgments, settlements,or final <br /> orders resulting from an action by any local, state, or federal environmental, hazardous waste, or public health <br /> enforcement agency? <br /> (For the purposes of this form,a notice of violation does not constitute an order and need not be reported unless <br /> it was not corrected and became a final order.) <br /> ® If you answered Yes,check this box and attach a listing of convictions,judgments,settlements,or orders and a copy <br /> of the cover sheet from each document. (see the Instructions for more infromation) <br /> DTSC 1772(1/93) Page 2 <br />