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BUSINESS OWNER/OPERATOR IDENTIFICATION FORMAN 1 2001 SIDE 1 <br /> BEGINNING DATE(1) Alpo) I. IDENTIFICATION WW"WIN <br /> QF#ICEOFEMEAGE t OFO <br /> BUSINESS NAME (4) BUSINESS PHONE(5) <br /> r a l 1 �/ 400 <br /> SITE ADDRESS (6) 5 S(0 nnq c j N ,%✓� <br /> ❑ U' =� <br /> Street No. Direction Street Name Street T e A dBld /Suite <br /> CITY (7) SToCfI /t7✓1 STATE(8) e n ZIP(9) Q5(:90DUN& (10) 1 1 SIC CODE(147DIGIT#)(11) <br /> BRADSTREET c-X ('_'59 1 <br /> OPERATOR (12) OPERATOR PHONE(13) <br /> NAME if t Pr Tf1C 1 97"1 - -fgo - 991 -7 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) OWNER PHONE(15) <br /> r�„Yler Tv1t �! � 780. Gcil <br /> OWNER ADDRESS (16) n <br /> (If different from Entries#6 or#41) FA L. 61 _p e,1G <br /> CITY(17) LQ 0 4 5 1 <br /> STATE(18) 7 X ZIP(19) �-d go <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(2 1) <br /> ro G� Urc� dog. 957" q�/C� <br /> CONTACT ADDRESS (22) <br /> different from Entries#6 <br /> or 1 ,;26 3 C ❑ �G 11{q /f 4 r f �� <br /> or#41) Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY(23) STATE(24) [a ZIP(25) <br /> Fc 9sata <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) �` NAME(3 1)��o � G� 0, ,,12 �r'' � vler <br /> TITLE(27) TITLE(32) <br /> 1 ' /GV) G U'G��� or f�ct�r <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> Fc7' . 7o C/fo 33 <br /> 24-HOUR PHONE(29) 1 24-HOUR PHONE(34) <br /> (After Business Hours) u C - j (/ (After Business Hours) �/ 7 Yl- 3�1 <br /> PAGER#(30) PAGER#(35) <br /> ti! <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) ❑YES (3NO 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) zt <br /> G <br /> NAME OF OWNER/OPERATOR(39) DATE(40) I <br /> o n V-e '/q/01 <br /> SIC 12100 <br />