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