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t <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION FORM SIDE 1 <br /> BEGINNING DATE(1) I. IDENTIFICATION (3)PAGE 1 OF _ <br /> BUSINESS NAME (4) BUSINESS E riPHONE(5) <br /> "�` G l oci) Lt L4(-p 2 <br /> SITE ADDRESS (6) ate© <br /> 1LdElno'yz)re_, ,o \,,,I� <br /> Street No. Direction Street Name Street Type A t/Bld Suite <br /> CITY (7) STATE(8) ZIP(9) <br /> DUN& (10) <br /> BRADSTREET STC CODE(4 DIGIT#) (11) <br /> OPERATOR (12) OPERATOR PHONE(13) <br /> NAME �� C <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) OWNER PHONE(15) <br /> OWNER ADDRESS (16) <br /> (If different from Entries#6 or#41) <br /> CITY(17) STATE(18) 0 ZIP(19) <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME{20) CONTACT PHONE (21) <br /> CONTACT ADDRESS (22) <br /> (If different from Entries#6 <br /> or#41) <br /> Street No. Direction Street Name Street Type A tBld Suite <br /> CITY(23) E7 STATE(24) E <br /> ZIP(25) <br /> Primary IV. EMERGENCY CONTACTS Second <br /> NAME(26) NAME(3 1) <br /> ary <br /> TITLE(27) <br /> TITLE(32) <br /> BUSINESS PHONE(28) BUSINESS PHONE(33) <br /> 24-HOUR PHONE(29) <br /> (After Business Hours) 24-HOUR PHONE(34) <br /> (After Business Hours) <br /> PAGER# (30) PAGER#(35) <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) Q 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) t, <br /> i1 <br /> NAME OF OWNER/OPERATOR(39) DATE(40) <br /> SJC 12/01 <br />