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BUSINESS OWNER/OPERATOR IDENTIFICATION.FORM SIDE 1 <br /> BEGINNING DATE(1) I. IDENTIFICATION �N l �j a(j (3) PAGE I OFO <br /> BUSINESS NAME (4) �� BUSINESS PI� R(5) <br /> q 2 ,17- q`f-3. 2�SZ <br /> SITE ADDRESS (6) 2 2 S0 ❑ STEZJA�ZT �S7 <br /> Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY (7) 6TO C7rkJ STATE(8)® ZIP(9) —L� 5 -324-* <br /> � <br /> DUN & (I( ) 8r,?& 3'722(c SIC CODE (4 DIGIT#)(II)��� �/,�T <br /> BRADSTREET <br /> OPERATOR (12) �/� OPERATOR PHONE(13) <br /> NAME �OPX7.T �M'A /✓7E <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) OWNER PHONE(15) <br /> RoG'�r r-. AMArAn17E- <br /> R.3/ <br /> OWNER ADDRESS (16) <br /> (If different from Entries#6 or#41) 155 FA1,24Lr-vN 07, <br /> CITY(17) STATE(18) L!>4� ZIP(19) <br /> AP i C5 r5o 03 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) F (Ka_1 ST/A1,4 LLE CONTACT PHONE(2 1) � �?y 3 z4✓3 <br /> CONTACT ADDRESS (22) IF11 <br /> (If different from Entries#6 <br /> or#41) Stree[No. Direction Street Name Street Type A t/Bld•/Suite <br /> CITY(23) STATE(24) "LIP(25) <br /> ST0CkTDnI G1 915265 <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(3I) <br /> �S001T WV LL.M.Af J 1&&WT I WA141JIE <br /> TITLE(27) TITLE(32) <br /> 0PEK114 J(t0AlS 1VK'JA-6 bV,_ O�N� <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> �l <br /> *4 <br /> 24-HOUR <br /> y�z <br /> 24-HOUR PHONE(29) ,, 24-HOUR PHONE(34) <br /> (After Business Hours) '- "T�' � '� (After Business Hours) C-'31 - &f�� <br /> PAGER#(30) PAGER#(35) <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) [ YES N 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 PRF.PARER (38) OA-0—/57A/A LEE" <br /> NAME OF OWNER/OPERATOR(39) DATE(40) <br /> SIC 12/00 <br />