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INESS MTJTIFICATIONFOR'WI °= Account <br /> 8 <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4) AND R AUTO REPAIR BUSINESS PHONE(5) 09-239-7492 <br /> SITE ADDRESS (6) 70 ❑ UTTON VE <br /> Street No. Direction Street Name <br /> CITY (7) ANTECA STATE(8)FA ZIP(9) 5366 <br /> DUN& (10) SIC CODE(4 DIGIT#)(1 l) <br /> BRADSTREET /A 538 <br /> OPERATOR (12) OPERATOR PHONE(13) <br /> NAME UFUS ROBLES 09-230-5005 <br /> lI.BUSINESS OWNER <br /> OWNER NAME(14) UFUS ROBLES OWNER PHONE(15) 09-230-5005 <br /> OWNER MAILING ADDRESS (16) <br /> Of different from site address) 22 S AIRPORT WAY <br /> CITY(17) ANTECA STATE(18) ZIP(19) 5337 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) CONTACT PHONE(21) <br /> RUFUS ROBLES 09-230-5005 <br /> MAILING ADDRESS(22) <br /> (If different from business <br /> mailing address) <br /> Street No. EDirection Street Name tree[Type ApUBldg/Supe <br /> CITY(23) STATE(24) ❑ ZIP(25) <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(3 1) <br /> �UFUS ROBLES N/A <br /> TITLE(27) TITLE(32) <br /> �WNER /A <br /> BUSINESS PHONE(28) k092305005 BUSINESS PHONE(33) /A <br /> 24-HOUR PHONE(29) 092989184 24-HOUR PHONE(34) /A <br /> PAGER#(30) /A PAGER#(35) /A <br /> IN <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 involving the EHS. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION(37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER(38) /A <br /> NAME OF OWNER/OPERATOR(39) N/A DATE(40) <br /> DATE REC'D: 5/28/08 <br />