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BUSINESS OWNER/OPERATOR IDENTIFICATION Account#: <br /> FORM <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4) CIRCLE K#2701205 BUSINESS PHONE(5) 09-858-4116 <br /> SITE ADDRESS (6) 16470 AMBRIDGE <br /> treat o Dimouc,n Stract Name ` street'ly ` pVg wte <br /> CITY (7) ATHROP STATE(8)FA7 ZIP(9) 5330 <br /> DUN& (10) 15-156.7054 SIC CODE(4 DIGIT#)(11) 541 <br /> BRADSTREET <br /> OPERATOR (12) OPERATOR PHONE(13) <br /> NAME COMPANY OPERATED 09-858.4116 <br /> II.BUSINESS OWNER <br /> OWNER NAME(14) HtCLE K STORES INC 1 OWNER PHONE(15) 51-270-5193 <br /> OWNER MAILING ADDRESS(16) 95 E RINCON STREET SUITE 150 <br /> (If different from site address) <br /> CITY(17) ORONA STATE(18) CA ZIP(19) 2879 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) ICH GOSSETT CONTACT PHONE(21) 51-270.5193 <br /> MAILING ADDRESS(22) <br /> (H different from site address 95 INCON ST TE 150 <br /> Street o. trechon Street Name L t—$—me[1„ype p g urte <br /> CITY(23) ATE(24) CA ZIP(25) 2879 <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(31) <br /> ERVICE CONTACT CENTER RRANCE NUTT <br /> TITLE(27) TITLE(32) <br /> 4 HOURS ARKET MANAGER <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> 66-805-4357 09.628.8642 <br /> 24-HOUR PHONE(29) 66-805-4357 24-HOUR PHONE(34) 09-628-8642 <br /> PAGER#(30) F/A PAGER#(35) F/A <br /> EXTREMELY HAZARDOUS SUBSTANCES(EHS) <br /> ON-SITE EHS (36) �—= If yes,and above Threshold Planning Quantities,attach a sheet of paper with a general <br /> description of the process and principle equipment involved with the EHS. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION(37) Provide information requested on the 2nd page of this form <br /> NAME OF DOCUMENT PREPARER(38) TANTEC CONSULTING INC.-STEVE SKANDERSON <br /> DATE(40) <br /> NAME OF OWNER/OPERATOR(39) RICH GOSSETT �_ r <br />