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BUSINESS IDENTIFICATION FORM <br />• <br />• <br />4GER/CELL 209-609-0478 CELL PAGER/CELL NA <br />UMBER (30) NUMBER (35) <br />EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br />Page 2 of 3 <br />SITE EH&S (36) NOIf yes, and above Threshold Quantities, attach a sheet of paper with a general <br />description of the process and principle equipment. <br />iITIONAL LOCALLY COLLECTED INFORMATION (37) <br />1ME OF DOCUMENT PREPARER RICKY CHAM <br />8) <br />BUSINESS MAILING AND BILLING INFORMATION <br />MAILING ADDRESS (41) <br />(If different from Site Address (6), otherwise leave blank.) <br />NOTE: ALL TIME SENSITIVE AND OFFICIAL CORRESPONDENCE WILL BE SENT TO THIS ADDRESS <br />NUMBER DIRECTION STREET NAME <br />I.-Irt\ra <br />LLING ADDRESS (42) <br />different from Mailing Address (41), otherwise leave blank.) <br />TE:INCLUDE "CARE OF' INFORMATION <br />NUMBER DIRECTION STREET NAME <br />STATE <br />ADDITIONAL BUSINESS INFORMATION <br />STREET TYPE <br />KAW <br />STREET TYPE <br />ZIP <br />OF R Single Owner O Corporation O Partnership C) Public Agency <br />,NIZATION (43) <br />AFFED SITE NO <br />FORK (44) <br />SSOR PARCEL NO. (45) 104-370-14 <br />IERTY OWNER HOK MA PHONE NO. (47) <br />E (45) <br />OWNER 5033 BAYVIEW CIR. <br />(48) <br />STREET ADDRESS <br />957-4641 <br />http://sjoesdata.org/oes_hmmp/section_tables/CHMIRF_ps_review.lasso?-Database=tran... 12/28/2009 <br />