Laserfiche WebLink
BUSINESS OWNER/OPERATOR IDENTIFICATIOPWAVED SIDE I <br /> BEGINNING DATE(1) I. IDENTIFICATIONdAN t 1 2001 (3)PAGE I OF[= <br /> BUSINESS NAME (4) ? ° 5�S <br /> SITE ADDRESS (6) s yy3 �✓ �y�wQy 99 � /r/,� <br /> Street No. Direction Street Name Street T e A [/Bld /Suite <br /> CITY (7) STATE(8) ZIP(9) <br /> 9Saao <br /> DUN& (10) SIC CODE(4 DIGIT#)(11) <br /> BRADSTREET 77 <br /> OPERATOR (12) / OPERATOR PHONE(13) <br /> NAME Prv�t/iS /� rt ,409-960—s/Os <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) OWNER PHONE(15) <br /> etf ,e: S sfwns 3a-6da —S'��8 <br /> OWNER ADDRESS (16) �7 m y �d� ����� <br /> (If different from Entries#6 or#41) /Q 1✓/ rWe e ,c-O <br /> CITY(17) ace STATE(18) �/� ZIP(19) <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) 2,57," <br /> CONTACT PHONE(2 1) <br /> ,l�c. lcxt_ <br /> CONTACT ADDRESS (22) <br /> or different from Entries#6 Jlj/ IF <br /> #41) Street No. Direction Street Name Street Type A t/Bld /Suite <br /> CITY(23) STATE(24) EZIP(25) <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) � /I /( NAME(3 1) <br /> fy�Lerf� <br /> TITLE(27) 1Vq'C10_f'e r TITLE(32) <br /> a,L4, <br /> BUSINESS PHONE(28) �- - q`' 9 J��5 BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) ��� 7� - ��/ 24-HOUR PHONE(34) <br /> (After Business Hours) J -� (After Business Hours) _J <br /> PAGER#(30) PAGER#(35) l+ `n ""` `T r��, <br /> 3o -��a <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) 1 E]YES ©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) S/e �wR¢,T <br /> NAME OF OWNER/OPERATOR(39) 11_�)// '/z <br /> � r DATE(40) <br /> S)C 12/00 <br />