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COMPANY NAME: ID No.: 4 GOL'(,;5 Al <br /> I. GENERAL INFORMATION (Continued) (See instructions on reverse) <br /> H. TREATMENT SITE ID NUMBER <br /> i�RD D 0 0 1„ 3.1 ,r't),rl <br /> I. TREATMENT SITE NAME <br /> J. TREATMENT SITE ADDRESS OR LEGAL DESCRIPTION OF SITE LOCATION <br /> S TO k T n NI P I. A t4 f <br /> 15 NRJ `( D• � IJ � <br /> (naatw( <br /> 5 t <br /> T!0. CA LT6Z, 0, 1 , - <br /> am (zip code( <br /> SRN Saft (� � I ,rJ <br /> COYntr) <br /> K. TREATMENT SITE CONTACT PERSON <br /> 6.1;.r,VA r, ( 1J 14i1'.0 Dl _ I I I I I � O•tJ A, L,� <br /> (Lan NCn ) ( int Name) <br /> LSnJ - L�.1G=J <br /> iWanen&NumaVl(ftp Coag atW NumwN <br /> L. TREATMENT SITE OWNERSHIP STATUS: <br /> ❑Federal ❑State ❑ Local Government 1,�a Private ❑ Publicly Held Stock ❑ Other Entity <br /> M. IS TREATMENT SITE LOCATED ON INDIAN LANDS? ❑ Yes ZA No <br /> N. SIC CODES (4 DIGIT, IN ORDER OF PRIORITY) <br /> 5 I �, I , PfP01�i�M SfW A!E <br /> 1. FIRST 2. SECOND <br /> 3. THIRD 4, FOURTH <br /> O. DATE(S) TTU WILL BE LOCATED AT THIS SITE <br /> START DATES END DATES ❑ If additional space Is needed. attach a <br /> MO-DAY YR I separate piece of paper with the additional <br /> Information, using the same format and place a <br /> check In this box. <br /> Dlstrtbutlon: DISC—WhNs and Yellow; NofMer—Pink and instnlctlons <br /> 017C wV11(11191) Page 2 of 5 <br />