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if <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION PAGE_. SIDE 1 <br /> CALENDAR YEAR BEGINNING(1)= ENDING(2) ---(3)PAGE 1 OF� <br /> BUSINESS NAME (4) BUSDSS PHONE(5) <br /> SITE ADDRESS (6) <br /> Street No. Direction Street Name Street T e A tBld /Suite <br /> CITY (7) / STATE(8) ZIP(9) <br /> Q. <br /> DUN& (10) J �— SIC CODE(4 DIGIT#)(11) <br /> BRADSTREET <br /> NPAME TOR �1 a 111�� OPERATOR PHONE(13) <br /> OWNER INFORMATION <br /> OWNER NAME(14) OWNER PHONE(15) <br /> OWNER MAILING ADDRESS(16) <br /> (If different from site address) <br /> CITY(17) STATE(18) ZIP(19) <br /> ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20 j CONTACT PHONE(2 1) <br /> /G' X {J 7 Br <br /> MAILING ADDRESS(22) <br /> (If different from site address) (� � <br /> StreeNo.t Direction Street Nwne Street Type A t/Bld Suite <br /> CITY(23) STATE(24) ZIP(25) <br /> Primary EMERGENCY CONTACTS Secondary <br /> NAME(26) nn ,�17 NAME(31) � <br /> / C' <br /> 11611 <br /> TITLE(27) TITLE(32) <br /> BUSINESS PHONE(28) D D BUSINESS PHONE(33) <br /> a <br /> 24-HOUR PHONE(29) ` L'. 24-HOUR PHONE(34) <br /> PAGER#(30) PAGER#(35) <br /> ACUTELY HAZARDOUS MATERIALS (AHM) <br /> ON-SITE AHM (36) YES NO If yes,and above Threshold Planning Quantities,attach a sheet of paper with a general <br /> description of the process and principle equipment. <br /> ADDITIONAL LOCALLY COLLECTED INFORMA 37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER(38) J h <br /> NAME OF OWNER/OPERATOR(39) DATE(40) A / i12/96 ] <br /> i <br /> tit <br /> Sir <br />