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BUSINESS OWNER/OPERATOR IDENTIFICATION FORM SIDE 1 <br /> JAN 2001 <br /> BEGINNING DATE(1) I. IDENTIFICATION SANJFO�,At�WINy06}JN�Yt`GE I OF� <br /> BUSINESS NAME (4). BUSI R%fM�'E�t� 'y PEFMeES <br /> macI2vr ! 4 3_ <br /> SITE ADDRESS (6) yi3Q 14 <br /> S�-b a� l^1 /�alZrt�2T r79�iwe�3 <br /> Street No. Direction Street Name Street TN pe Apt/Bldg/Suite <br /> CITY (7) STATE(8) ZIP(9) <br /> DUN & (10) �- SIC CODE(4 DIGIT#)(1 l) _ <br /> BRADSTREET I Cl I 2 ) 1 Z <br /> OPERATOR (12) 1 ) f OPERATOR PHONE(13) `p r <br /> NAME 'y�>L1�7r'M` h. � ���i <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) S__ OWNER PHONE(15) <br /> OWNER ADDRESS (16) <br /> (If different from Entries#6 or#41) <br /> CITY(17) j; <br /> vt� STATE(IS) ® ZIP(19) <br /> �9" III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(2 1) <br /> 43 <br /> CONTACT ADDRESS (22) <br /> (If different from Entries#6 F <br /> or#41) Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY(23) S + STATE(24) ZIP(25) <br /> � c :S <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(3 1) <br /> TITLE(27) 1 cu, TITLE(32) <br /> iv- -Pi �� i�P Cu�1Kz�� <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) 24-HOUR PHONE(34) 2�c. <br /> (Aller Business Hours) �)f `T i7.'7�QZ.� J (After Business Hours) j <br /> PAGER#(30) PAGER#(35) <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) YES [KNO 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 PRF-PARER (38) <br /> 1�2�1 L C014 <br /> NAME OF OWNER/OPERATOR(39) ✓ DATE(40) JIJZ /of <br /> i— SIC 12/00 <br />