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BUSIN19SS OWNER/OPERATOR IDENTIFICATION FOR t - ` ` SIDE I <br /> BEGINNING DATE(1)�� I. IDENT CATION (3) PAGE I OFC // <br /> BUSINESS NAME (4) <br /> BU o ( PE4�1,y y��D/p�// <br /> SITE ADDRESS (6) <br /> RECEIVED Street XNo. /�Directi/on treet Name S[ree[T e A t/Bld /Suite <br /> CITY SEP 2 5 200 (7) <br /> L/lr1/ STATE(8)M ZIP(9) <br /> DUAl1UIN000NI wwl,.4 <br /> r/q SICCODE(4 DIGIT#)(11) <br /> OPERATOR (12OPERATORPHONE(13)NAME <br /> II. BUSINESS OWNER <br /> OWNERNAME(14) ItItehlYz / 1 OWNERPHONE(15) /4/4/— <br /> OWNER ADDRESS (16) 7`7// <br /> (If different from Entries#6 or#41) <br /> CITY(17) STATE(I S) ZIP(19) <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(2 1) <br /> — <br /> CONTACT ADDRESS (22) ❑ �� <br /> (If different from Entries#6 <br /> or#41) Street No. Direction Stree[Name Stree[T e A t/Bld,,/Suite <br /> CITY(23) STATE(24) ZIP(25) <br /> Primary IV. EMERGENCY CONTA Secondary <br /> NAME(26) NAME(31) <br /> TITLE(27) TITLE(32) <br /> BUSINESS PHONE(28) �i — 6'/ BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) �p/e !v 24-HOUR PHONE(34) <br /> (After Business Hours) �G� /- (After Business Hours) <br /> PAGER#(30) All— PAGER#(35) <br /> EXTyAnVILE1,Y HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) 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 INFO N(37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER (38) �. <br /> NAME OF OWNER/OPERATOR(39) 1110 1 DATE(40) U Q� <br /> d � SIC 12/00 <br />