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BUSINESS OWNER/OPERATr IDENTIFICATION FORMSIDE 1 <br /> AD L I.1 <br /> EGINNING DATE(1) I.IDENTIFICATION (3)PAGE 1 ED <br /> BUSINESS NAME (4) BUSINESS PHONE(5) APR 1 i 200 <br /> s l <br /> SITE ADDRESS (6) t y G t 01FIGf OFEMER6ENOym� yg <br /> Street No. Direction Street a e Street Type Apt/Bldg/Suite <br /> CITY (7) STATE(8) ZIP(9)k75_ -7 <br /> DUN& (10)� ' SIC CODE(4 DIGIT#) (11) <br /> BRADSTREET + SFf Z <br /> NAME (12) OPERATOR PHONE(13) <br /> ME <br /> Com. <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) OWNER PHONE(15) <br /> OWNER ADDRESS 6) <br /> (If different from Entries#6 or#41) e <br /> CITY(17) STATE(18) ZIP(19)El <br /> C? � / <br /> III. ENVIRONMENTAL CONTACT [ V <br /> CONTACT NAME(20) CONTACT PHONE(2 1) <br /> 0 <br /> CONTACT ADDRESS(22) <br /> (If different from Envies#6 �� <br /> or#41) Street No. Direction Street N me _ Street Type A t/Bld Suite <br /> CITY(23) STATE(24) El ZIP(25) <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(3 1) <br /> TITLE(27) TITLE(32) <br /> LlJG <br /> BUSINESS PHONE(28) u BUSINESS PHONE(33) —7_) 7— <br /> 24-HOUR PHONE(29) 24-HOUR PHONE(34) <br /> (After Business Hours ' <br /> Pl' —L' (After Business Hours) <br /> PAGER#(30) 1':1� PAGER#(35) r <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) EJYES [—]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) <br /> NAME OF OWNER/OPERATOR(39) DATE(40) <br /> -a6 -o <br /> SIC 12/03 <br />