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BUSINESS OWNER/OPERATOR IDENTIFICATION FORM SIDE-1 <br /> BEGINNING DATE(1) I. IDENTIFICATION (3)PAGE 1 OFE--= <br /> BUSINESS NAME (4) BUSINESS PHONE(5) <br /> o C L <br /> SITE ADDRESS (6) <br /> 3Y3a-.� ►-� e 2a e � �c� <br /> Street No. Direction Street Name Street Type A t/I31dg/Suite <br /> CITY (7) STATE(8) ZIP(9) <br /> DUN& (10) SIC CODE(4 DIGIT#)(11) <br /> BRADSTREET "� -�' r�`Z-- <br /> OPERATOR (12) OPERATOR PHONE(13) <br /> NAME C p :i C !' C <br /> II. BUSINESS OWNER <br /> 0WiNER NAME(14) J O%i`1ER PHONE(15) <br /> OWNER ADDRESS (16) , <br /> (If different from Entries#6 or#41) <br /> CITY(17) STATE(18) ZIP (19) <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) �. CONTACT PHONE(2 1) <br /> CONTACT ADDRESS (22) <br /> (If different from Entries##6 �� e <br /> or#41) IF I I <br /> Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY(23) STATE(24) ZIP(25) <br /> `Z� L 1�il ��S2-46 -J <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(31) <br /> t` <br /> TITLE(27) TITLE(32) <br /> t <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) 24-HOUR PHONE(34) <br /> (After Business Hours) (After Business Hours) <br /> PAGER# (30) PAGER#(35) <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) 1 [:]YES ENO 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 /> J <br /> NAME OF OWNER/OPERATOR(39) - `Z DATE(40) G C� <br /> C <br /> — � SJi✓ 12/90 <br />