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BUSINESS OWNER/OPERATOR IDENTIFICATION FORM SIDE I <br /> BEGINNING DATE(1)® L IDENTIFICATION (3) PAGE I OF E= <br /> BUSINESS NAME (4) q D 1XI k rl( va BUSINESS PHONE(5) <br /> SITE ADDRESS (6) FN q <br /> Street Street Direction Street Name Street T e A [/Bld /Suite <br /> CITY (7) Awm STATE(8) �� ZIP(9) <br /> DUN& (10) SIC CODE(4 DIGIT#)(11) �,✓� <br /> BRADSTREET b552$� 88b /���'�y� <br /> OPERATOR (12) ( rr1 ry (65 ATOR PHONE(13) <br /> NAME <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) OWNER PHONE(15) <br /> OWNER ADDRESS (16) �o� N <br /> (If different from Entries#6 or#41) T <br /> CITY(17) m STATE(18) ® ZIP(19) <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) od n I M i SOYA CONTACT PHONE(2 1) <br /> CONTACT ADDRESS ( <br /> (If different from Entries#66 1 t�Y 1 �1 I IF <br /> or#41) Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY(23) � STATE(24) El ZIP(25) <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) Mach �arrisD►� NAME(31) I�grry 1�Glrrdsol/1 <br /> TITLE(27) TITLE(32) <br /> T�'e�id�- oi,�ner Vice Ffesi eXrr ovjner <br /> BUSINESS PHONE(28) n� n ��-7�A BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) ISI _fp C�r IQ 24-HOUR PHONE(34) <br /> (After Business Hours) (� U'✓�p (After Business Hours) �`1 •✓�J�I 1 <br /> PAGER#(30) PAGER#(35) <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE ERS (36) 1 E]YESNO 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) 11 is �4arri son <br /> NAME OF OWNER/OPERATOR(39) DATE <br /> Mi�c.4� �+arr� so VlJ <br /> SIC l2/00 <br />