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BUSINESS OWNER/OPERATOR IDENTIFICATION FORM SIDE 1 <br /> BEGINNING DATE(1) Zcx�z I. IDENTIFICATION iANJUAUUt�I�NN1�1��1 <br /> NAGE 1 OF� <br /> BUSINESS NAME (4) BUSINES§- WI )'C VI <br /> S��y�� � t,_o� � -t-e�c.1� CL-t-1�rE� Zo9.3ta31. 1�k31 <br /> LSI2 5 2002b) <br /> FEB 2 5 2002 I�Itg81 �'-• (�t�="w �S <br /> Street No. Direction Street Name Street Type A t/Bld Suite <br /> CSMJUAUUING0UNIC STATE(8) ZIP(9) <br /> ,HRCEOFEMER6ENCYSE E: Vp��,s , v C.A iSzZp <br /> DUN& (10) �/� SIC CODE(4 DIGIT#)(11) 15 $ <br /> BRADSTREET <br /> OPERATOR (12) OPERATOR PHONE(13) <br /> NAME E2t L tel. 'Z09.3u9. 14'51 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) OWNER PHONE(15) <br /> �2tc_ a- �e„aL. Zc�9 3ca9. r�l-31 <br /> OWNER ADDRESS (16) <br /> (If different from Entries#6 or#41) <br /> CITY(17) STATE(18) E:1 ZIP(19) <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(21) <br /> CONTACT ADDRESS(22) F <br /> (If different from Entries#6 <br /> or#41) Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY(23) F I STATE(24) El ZIP(25) <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(3 1) g/M. <br /> TITLE(27) TITLE(32) <br /> �P£S.pEx1TY• ` q .3 <br /> BUSINESS PHONE(28) 'Z09 3U9 . 1BUSINESS PHONE(33) <br /> �13t Zoi•'31e5. 1�l31 <br /> 24-HOUR PHONE(29) 24-HOUR PHONE(34) <br /> (After Business Hours) Zo9.3L.9. 1 x-31 (After Business Hours) <br /> PAGER#(30) �/ PAGER#(35) <br /> r4 <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) U 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) <br /> A . tSE.oL <br /> NAME OF OWNER/OPERATOR(39) DATE(40) <br /> �« ✓�. 1�C--tel_ 'Z tt �OZ <br /> SJC 12/01 <br />