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BUSINESS OWNER/OPE OR IDENTIFICATION PAGt'�D SIDE 1 <br /> till 2 5 MR <br /> CALENDAR YEAR BEGINNING(1) / / ENDING(2) (3)PAGE IIIOFF q� <br /> BUSINESS NAME (4) So /D / 1v2t� 3Z�9� BUS SP Q13",' I-JtY� —�G <br /> SITE ADDRESS (6) <br /> Street No. Direction Street Name Street T e A tBld Suite <br /> CITY (7) S{/ / / � STATE(8)® ZIP(9) <br /> DUN& (10)��( 10� SIC CODE(4 DIGIT#)(11) <br /> BRADSTREET / <br /> OPERATOR (12) / / OPERATOR PHONE(13) <br /> NAME T V�-CS4 <br /> OWN/ER INFORMATION <br /> OWNER NAME(14) O( /d( l_0C OWNER PHONE(15) 2//7/ �,// 72 0 <br /> OWNER ADDRESS (16) �� (�� 7// <br /> (If different from Entries#6 or#41) <br /> CITY(17) STATE(18) r� ZIP(19) 7s2 <br /> 2/ <br /> ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(21) rSO 3 7 77- 77/3 <br /> D� 2 7r'1[-ta <br /> CONTACT ADDRESS ( �� <br /> (If differentfrom Entries#6 <br /> or#41) Street No. Direction Street Name Street Type A t/Bld Suite <br /> CITY(23) STATE(24) ZIP(25) <br /> �or41a.,"z----j 02 F722-3 -1 <br /> Primary EMERGENCY CONTACTS Seton <br /> NAME(26) NAME(3 1) <br /> TITLE(27) r TITLE(32) <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) , / 24-HOUR PHONE(34) <br /> (After Business Hours) o �7..r 2 �b (After Business Hours) <br /> PAGER#(30) PAGER#(35) <br /> /6 IF10- z <br /> TREMELY 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 INFORMATION(37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER(38) %1 F/moor L G <br /> NAME OF OWNER/OPERATOR(39) / �a..0 <br /> /DATE(40) bl <br /> OJ" �rno <br /> / STC 12/97 <br /> LO��or�s <br />