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Referred by DES Specialist <br />OES REFERRAL Initial/Date: ;14 <' <br />HMMP Approved by DES Supervisor <br />Initial/Date: <br />Business Name: -0456 ZtiG <br />Mailing Address: 3r/6 /�i9GFr/O Ci/�C,/6i LOOI 4Sa�/O <br />Site Address: 13 y6 /711 PGG/O C/elC�, LOd1 ri'Sl �/6 <br />Telephone: Kgo41 <br />Nature of Business: }�,COC6SfD� <br />Is Business a Single Owner, Corporation, Partnership, Other?Indicate Name <br />and Address:.27W �-'�e -ZG <br />Current Owner's Name: .06C e4lrz� <br />Mailing Address: g; � 6011.E r -!r,' eo <br />Current Manager's Name: �S71-1440 <br />Job Title: <br />Mailing Address: —23f/! "-rave <br />HMMP Contact: <br />Responsible Party for Completing the HMMP <br />Job Title: Ul/i <br />Mailing Address: <br />Property Owner:���w <br />Mailing Address: <br />OES/HMMP Packet Mailed On: n• /ICY <br />OES/HMMP Status (Reject/No Respon /Approve): <br />OES/Personal Contact Date(s): <br />OES 10 Day Warning Date: <br />IDES observations of hazardous material(s) on premises. List the types and <br />amounts of chemicals that qualify business for program. <br />DAM 0 Day Letter Sent: <br />DA/Response to 10 Day Letter: _ <br />OES/Compliance Due Date (10 <br />DA/Complaint Filed: <br />DA/Status: <br />14 Days): <br />Is business till in <br />operation? Y- N <br />Date verified on <br />Meiling: - V-1 <br />Physical: <br />Are these persons <br />currently working? <br />Y - N <br />Y - N <br />Y - N <br />Property Owner Notifi <br />Date: <br />Was there a response? <br />Y - N <br />Date verified previous <br />to DES Referral. <br />Initial/Date:.-'-- _. <br />