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BUSINESS OWNER/OPERATOR IDENTIFICATION DPe�l SIDE 1 <br /> BEGINNING DATE(1) I. IDENTIFICATION SAN JOAQUINCOUNIYf3� PAGE'IQF , 0� <br /> E OF EMERGENCY SERIAC S <br /> BUSINESS NAME (4) //" ' BUSINESS PHONE(5) <br /> (.JCIr�I1rr„ Pum >~ 1�rY i 9-7� 5s ¢$ <br /> 7- ' <br /> SITE ADDRESS (6) r/ 7 7S�s� <br /> / 77S� 111VII w <br /> Street No. Direction Street Name Street T e__ A t/Bld*/Suite <br /> CITY (7) STATE(8) ZIP(9) <br /> �Cc�cKEFbRD 9S 3 7 <br /> DUN& REET (1O) (wt 3 / 0 g,y– SIC CODE(4 DIGIT#)(11)BRA1 7 Y / <br /> OPERATOR (12) OPERATOR PHONE(13) <br /> NAME /1"(J/V -9-727 <br /> It. BUSINESS OWNER <br /> OWNER NAME(14) /�/V /� C�t1 '��'t r InC OWNER PHONE(15) <br /> /r ,2�-7.77-S5i8 <br /> OWNER ADDRESS (16) <br /> (If different from Entries#6 or#41) ��7/YIP_ QJ( <br /> CITY(17) STATE(18) GA ZIP(19) <br /> ,�oc,+lEf�RD 9Sa � <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) ON CONTACT PHONE(21) <br /> CONTACT ADDRESS ( <br /> different from Entries#66 <br /> or 56;/W <br /> or#41) Street No. Direction Street Name Street Type A)t/lild /Suite <br /> CITY(23) F —11 STATE(24) El ZIP(25) <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(31) <br /> Lyle 4570 V,ln I/PV/V <br /> TITLE(27) TITLE(32) <br /> ®res - v,-C 4z Qres - <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) 3 24-HOUR PHONE(34) <br /> t.(f'�(After Business Hours) „ 3�' (After Business Hours) <br /> t z'`5 S �' <br /> PAGER#(30) ( Y U/V z-- PAGER At(35) N01V E <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) YES NO If yes,and above Threshold 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) OAA CIA r?n <br /> NAME OF OWNER/OPERATOR(39) � DATE(40)oiv Go�,rlr+ <br /> SIC 12/00 <br />