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06/14/2005 10:14 2093399097 SANBORN CHEVROLET PAGE 02 <br /> BUS NESS OWNER/ PERaTOR IDENTIFICATION FORM SIDE I <br /> sEGINNI, DATE(1) <br /> 1. IDENTIFICATION (3) PAGE IOF= <br /> BUS[NES NAME (4) BUSINESS PHONE (5) <br /> A ire C. Qv;ul-Qr a►1C71 <br /> SITE ADr. RESS (6) ! <br /> j � r� a �hQ���ie�- I..ci►,�. <br /> Street No. Direction Street NameStreet Tv A t/BIdvJSuite <br /> CITY (7) STATE(8) ZIP(9) <br /> DUN & (l0) SIC CODE (4 DIGIT #) (11) <br /> BRADST EFT <br /> OPEkAT R (12) OPERATOR PHONE (13) <br /> N AME <br /> II. BUSINESS OWNER <br /> OWNER AME(la) JJ rr OWNER PHONE (I�) f� �� <br /> OWNER DDRESS _ . (16 <br /> (If differe t from Entries#6 or#.l1) <br /> CITY (17 STATE (I 41 ?.1P(19) <br /> III. ENVIRONMENTAL CONTAur <br /> CONTA NAME (20) � CONTr1CT 11 JUNE (2 1) r � _r�. av <br /> -JE- tic V <br /> CONTA ADDRESS (22) <br /> tlt diffcrc t from Entries#G <br /> or #41) Street No. Direction Street Name Street Type <br /> A t/BId�ISuue <br /> CITY (2 STATE t24) ZIP(25) <br /> Primary IV. EMERGENCY CONTACTS Second <br /> NAME( ) NAME (3 1) <br /> �aokje, S C.Rc.TOtj � <br /> TITLE u�-�I� <br /> TITLE(32) M� <br /> ( ) fIr 6 ' ' <br /> {?yL k)c ," cx pct 4ee--I'z-_ <br /> BUSIN S PHONE (28) BUSINESS PHONE(33) <br /> 1 &_E: <br /> 24-HO PHONE(29) ,-- 24-HOUR PHONE (34) <br /> (After B iness Hours) ! paJ (After Business Hours) Eq <br /> PAGER (30) 1 PAGER #(35) <br /> E L H RE UB E ( H ) <br /> ON-SIT EHS (36) 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 /> ADDITI NAL LOCALLY COLL CTED INFORMATION (37) Provide information requested on the back of this form <br /> NAME fF DOCUNII N'f PREPER (38) � <br /> NAME 3F OWNEWOPERATOR (39) ` ll rr < DATE (40) <br /> S1(. I'/lil <br />