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Rev.6/26//2001 <br /> Page 5 of 5 <br /> Respondent Information: <br /> �. Name: o+hU L-09Omar5ino <br /> Title: Cr7-Owner' <br /> Firm: �,p <br /> Property Address: n0 E- Mato' <br /> Qto' <br /> Mailing Address (if different): S(o1 D E tlu t� <br /> ` S'A'DC.,{on UA `fS2I5 <br /> Property Assessors Parcel Number: 1-13- 2-10-05 <br /> ` (2a4) Ct+1- q(,S& <br /> Phone: / <br /> Respondent Relationship to Site: O,Gg ✓ Occupant Renter <br /> Type of Property: Commercial Industrial Residential <br /> b Preparer represents that to the best of the Preparer's knowledge the above statements and facts are <br /> true and correct and to the best of the Preparer's actual knowledge no material facts have been <br /> suppressed or misstated. <br /> User's Signature Date <br /> eparer's Signature Date <br /> Respo ent's SAature Date <br /> r <br /> P:\3916 East Main Street Development (Gmpe)\3916 E Main Street Development Phase I\Con-espondence\L.etters\Phase I <br /> Questionnaire(-05).doc <br /> Initials <br />