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BUSINESS OWNER/OPERAT' IDENTIFICATIONEiV611 SIDE 1 <br /> t iCl� <br /> u, I.IDENTIFICATION FEB F� b :,p.�.�NF; (3)PAGE 1 OFO <br /> Brr'n`� �4> ANSII�IN COON7Y (5) G/ _ <br /> SAN JUAUUIN CaVNTY E OF EMERGENCY SERVICES <br /> Street No. Direction Street Name tree[T e A tBld Suite <br /> RCITY ]ECEIVEb') sTATE(s)� ��(9) <br /> d5 20-2 <br /> BDi� (:. (10) 7-�/e A 7 j2 SIC CODE(4 DIGIT#) (11) <br /> 75 <br /> OPERATOR (12) OPERATOR,. DjLb ?� M 9- <br /> I1. BUSINESS OWNER <br /> OWNER NAME(14) �t jOWNER PHONE(I 5) / <br /> OWNER ADDRESS (1 t�� <br /> (If different from Entries#6 or#41) 2, <br /> CITY(17) STATE(18) ZIP(19) <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(21)Zw <br /> Q <br /> CONTACT ADDRESS(22) <br /> (If different from Entries#6 r7/vi <br /> or#41) <br /> Street No. Direction Street Name Street Type A tBld Suite <br /> CITY(23) STATE(24) ZIP(25)- <br /> 2 <br /> Primary IV. EMERGENCY CONTACTS =ndary <br /> NAME(26) NAME(3 1) <br /> TITLE(27) TITLE(32) <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) 24-HOUR PHONE(34) <br /> (After Business Hours) r (After Business Hours) 57 t <br /> PAGER#(30) PAGER #(35) <br /> FXTRENFELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) YES O 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) <br /> NAME OF OWNER/OPERATOR(39) DATE(40) <br /> 2 <br /> 91C 12/03 <br />