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Aft <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION FORM SIDE I <br /> BEGINNINGDATE(I)I� _� G _tl I. IDENTIFICATION (3) PAGE I OF[� <br /> BUSINESS NAME (4) BUSINESS PHONE(5) <br /> SITE ADDRESS (6) � <br /> Street No. Direction Street Name Street Type A t/Bldg/Suite <br /> CITY (7) STATE(8) ZIP(9) <br /> �o f, z/s <br /> DUN & (10) SIC CODE (4 DIGIT#)(11) <br /> BRADSTREET /r,'- �f�$'- 6S�L� y2 .7/ <br /> OPERATOR (121 OPERATOR PHONE(13) <br /> NAME [F�D-zX _ V-rg / <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) F OWNER PHONE(15) <br /> F�D�X F��/6�/7�✓�S7 � v�'- 3Z 3 - s'd <br /> OWNER ADDRESS (16) <br /> (If different from Entries#6 or#41) <br /> CITY(17) STATE(18) ZIP(19) <br /> .S , Tse �s/til- opL <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(211 <br /> G�,h Lcc yea-3z� - s�i <br /> CONTACT ADDRESS (22) <br /> (If different from Entries#6 / / ❑ ve c /+rlJ �a • 2�b'T <br /> or#41) b Street No. Direction StreetName Street Type Apt/Bid, uite <br /> CITY(23) STATE(24) ZIP(25) <br /> Sah TSc G4 � — obL <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) / NAME(3 1) <br /> TITLE(27) TITLE(32) <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> Zd - L -a _ -2� Z7 <br /> 24-HOUR PHONE(29) 24-HOUR PHONE(34) <br /> (After Business Hours) (After Business Hours) yTy7 <br /> PAGER#(30) PAGER# (35) <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE FHS (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 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 /> SJC 12/00 <br />