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BUSINESS OWNER/OPERATOR IDENTIFICATION PAGE! r I B 4 IDE 1 <br /> CALENDAR YEAR BEGINNING(1) ENDING(2)1!1r_3_PAGE 1 OFE:= <br /> BUSINESS NAME (4) AM JOAI` <br /> SITE ADDRESS (6) <br /> C7� DoraCl fee+ <br /> Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY (7) STATE(8)F ZIP(9) <br /> S��C J^`1 S D to <br /> BRA STREET (10) J V5 �� SIC CODE(4 DIGIT#)(11) <br /> OPERATOR (12) OPERATOR PHONE(13) <br /> NAMEilw_ <br /> _ �9_1 <br /> s_ <br /> OWNER INFORMATION <br /> OWNER NAME(14) OWNER PHONE(15) <br /> f avr � <br /> OWNER MAILING ADDRESS (16) 2 U�G _/'l S/ <br /> (If different from site address) �Jo off <br /> ' S 6e- QC. <br /> CITY(17) S Cr _ 1 STATE(18) EQ ZIP(19) v <br /> /v ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(21) <br /> MAILING ADDRESS IF <br /> (If different from site address) <br /> Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY(23) STATE(24) 1:1 ZIP(25) <br /> Primary EMERGENCY CONTACTS Secondary <br /> NAME(26) V7qr NAME(3 1)e lcroo d s I d ci f 150—Sc <br /> TITLE(27) 1 TITLE(32) <br /> 1 INov- j <br /> BUSINESS PHONE(28) , _ /S BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) 7�/ n l <br /> 24-HOUR PHONE(34) L/0 SL/` 7�/� <br /> PAGER# (30) t PAGER#(35) <br /> ACUTELY HAZARDOUS MATERIALS (AHM) <br /> ON-SITE AHM (36) YES NO If yes,and above Threshold Planning Quantities,attach a sheet of paper with a general <br /> description of the process and principle equipment. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION(37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER(38) l� , l/+ 1 �6 � n D <br /> C. <br /> NAME OF OWNER/OPERATOR(39) �l�9e IC? <br /> 1qU L DATE'40) <br /> (> <br /> SIC 12/96 <br />