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BUSINESS OWNER/OPERATOR IDENTIFICATION <br />BEGINNING DATE (1) tiu! [1ac� I. IDENTIFICATION <br />BUSINESS NAME (4)1 11R - A. , C n nS <br />SITE ADDRESS (6) <br />CITY (7) <br />SIDE I <br />j `we(3)PAGE I OF� <br />� <br />'sj_Z2� <br />25533 ® �Wj on From RD 0 <br />Street <br />BRA STREET (11))1 1101619 3 04L09 <br />OPERATOR (12)[Ronal '1hoK , <br />NAME <br />II. BUSIN <br />OWNER NAME (14) Ron J�nw- <br />OWNER ADDRESS (16) I <br />(If different from Entries #6 or #41) <br />CITY (17) 1 A,, <br />CONTACT NAME (20) <br />Street Name street Type A Ublo /smte <br />STATE (8)CA I <br />ZIP (9) ciF)m <br />SIC CODE (4 DIGIT #) (11) O �� <br />OPERATOR PHONE (13) (20q LPLP ZZ <br />I -5 <br />OWNER PHONE (15) /.�M\ <br />� �artl�e l�Rj}�dJ. <br />FE (18) � ZIP (19) <br />ENVIRONMENTAL <br />ahnKe- <br />CONTACT PHONE (2 1) j2 <br />1 \ �uu^ i <br />CONTACT ADDRESS (22) FF <br />(If different from Entries #6 2, J J�� ]LN j -HWy q"I <br />or #411 — — <br />CITY (23) <br />(ompe, <br />NAME (26) R Nn 0 <br />TITLE (27) Ow nC r <br />BUSINESS PHONE (28) lVILI\1 _ �I� <br />(2N)J �J3�O►q �?) <br />I:bhnKc- <br />24-HOUR PHONE (29) <br />(After Business Hours) <br />PAGER # (30) r <br />atreet [Name 3rrem i ype r+ unru <br />STATE (24) ZIP (25) LLZ2 0 1 <br />NCY CONTACTS Secondary <br />NAME (31) <br />0-,-rj whir ►11" <br />HTLE(32) I aCfCUN <br />BUSINESS PHONE (33) <br />24-HOUR PHONE (34) <br />(After Business Hours) / /45� ✓`� I <br />PAGER # (35) <br />ON-SITE EHS (36) 0 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) Dz h' ,/ <br />NAME OF OWNER/OPERATOR (39) No na A TL h n Kc, DATE (40) n <br />�-12- <br />SIC I2/00 <br />