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Regional Office: Initial assignment Application No: Check number: Re-assignment Date Received : Amount ($): 1. Company information: Legal Name: Other company name (if different than legal name): Mailing Address: Site Address (if different than mailing address): City, State, Zip Code: City, County, Zip Code: North American Industry Classification System (NAICS): Number of Employees: 2. Surface coating permit or registration: Surface coating of metal and/or plastic part or pro.

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