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UPCF Business Owner/Operator Identification Page nstructions Please submit the Business Activities page,the Business Owner/Operator Identification page,and Hazardous Materials Inventory-Chemical Description pages for all hazardous materials inventory submissions. For the inventory to be considered complete this page must be signed by the appropriate individual [Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form(UPCF)pages These data element numbers are used for electronic submission and are the same as the numbering used in Division 3,Electronic Submittal of Information.] Please number all pages of your submittal. This helps the Unified Program Agency(UPA)identify whether the submittal is complete and if any pages are separated 1 FACILITY ID NUMBER—Leave this blank This number is assigned by the UPA This is the unique number which identifies your facility 3 BUSINESS NAME-Enter the doing business as name 100 BEGINNING DATE-Enter the beginning year and date of the report (YYYYMMDD) 101 ENDING DATE-Enter the ending year and date of the report.(YYYYMMDD) 102 BUSINESS PHONE-Enter the phone number,area code first,and any extension 102a. BUSINESS FAX—Enter the business fax number,area code first 103 BUSINESS SITE ADDRESS-Enter the street address where the facility is located No post office box numbers are allowed. This information must provide a means to geographically locate the facility. 104 BUSINESS SITE CITY-Enter the city or unincorporated area in which business site is located 105 ZIP CODE-Enter the zip code of business site The extra 4 digit zip may also be added 106 DUN&BRADSIREET—If'subject to EPCRA,enter the Dun&Bradstreet number for the facility. The Dun&Bradstreet number maybe obtained by calling (610)882-7748 or on the web at www.dnb.com. 107 SIC NUMBER-Enter the primary Standard Industrial Classification System Number Required for EPCRA 107a NAICS NUMBER-Enter the primary North American Industrial Classification System Number 108 COUNTY-Enter the county in which the business site is located 108a. BUSINESS MAILING ADDRESS—Enter the mailing address to be used for all official business correspondence This mailing address must be filled in. 108b BUSINESS MAILING CITY-Enter the name of the city for the business mailing address. 108c STATE-Enter the two character abbreviation of the state for the business mailing address. 108d, ZIP CODE-Enter the zip code for the business mailing address The extra 4 digit zip may also be added 109 BUSINESS OPERATOR NAME-Enter the name of the business operator 110 BUSINESS OPERATOR PHONE.-Enter business operator phone number,if different from business phone,area code first,and any extension. 111. BUSINESS OWNER NAME-Enter name of business owner,if different from business operator 112 BUSINESS OWNER PHONE-Enter the business owner's phone number if different from business phone,area code first,and any extension 11.3 BUSINESS OWNER MAILING ADDRESS-Enter the owner's mailing address,if different from business mailing address 114 BUSINESS OWNER CITY-Enter the name of the city for the owner's mailing address,if different from business mailing address 115 BUSINESS OWNER STATE-Enter the 2 character state abbreviation for the owner's mailing address,if different from business mailing address 116 BUSINESS OWNER ZIP CODE-Enter the zip code for the owner's address, if different from business mailing address The extra 4 digit zip may also be added 117 ENVIRONMENTAL CONTACT NAME-Enter the name of the person,who receives all environmental correspondence 118 CONTACT PHONE-Enter the phone number,if different from Owner or Operator, for the environmental contact,area code first,and any extension. 119 CONTACT MAILING ADDRESS-Enter the mailing address where all environmental contact correspondence should be sent I 19a CONTACT EMAIL—Enter the email address of the environmental contact in 117,if the contact has one 120 CONTACT MAILING CIT Y-Enter the name of the city for the environmental contact's mailing address. 121 STATE-Enter the 2 character state abbreviation for the environmental contact's mailing address 122 ZIP CODE-Enter the zip code for the environmental contact's mailing address. The extra 4 digit zip may also be added 123 PRIMARY EMERGENCY CONTACT NAME-Enter the name of a representative to be contacted in case there is an emergency involving hazardous materials at the business site. The contact shall have FULL facility access,site familiarity,and authority to make decisions for the business regarding incident mitigation 124. TITLE-Enter the title of the primary emergency contact 125. BUSINESS PHONE.-Enter the business number for the primary emergency contact,area code first,and any extensions 126 24-HOUR PHONE-Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number,then the service answering the phone must be able to immediately contact the individual stated above. 127. PAGER NUMBER-Enter the pager number for the primary emergency contact,if available 128. SECONDARY EMERGENCY CONTACI NAME.-Enter the name of a secondary representative that can be contacted in the event that the primary emergency contact is not available the contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regarding incident mitigation. 129. TITLE-Enter the title of the secondary emergency contact. 130 BUSINESS PHONE-Enter the business telephone number for the secondary emergency contact,area code first,and any extension 131 24-HOUR PHONE-Enter a 24-hour phone number for the secondary emergency contact The 24 hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number,then the service answering the phone must be able to immediately contact the individual stated above 132 PAGER NUMBER-Enter the pager number for the secondary emergency contact,if available 133 ADDITIONAL LOCALLY COLLECTED INFORMATION - This space may be used for UPA to collect any additional information necessary to meet the requirements of their individual programs Contact UPA for guidance. 134. DATE-Enter the date that the document was signed (YYYYMMDD) 135 NAME OF DOCUMENT PREPARER-Enter the full name of the person who prepared the inventory submittal information 136 NAME OF'SIGNER-Enter the full printed name of the person signing the page. The signer certifies to a familiarity with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information,all the information submitted is true,accurate and complete SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE-The Business Owner/Operator,or officially designated representative of the Owner/Operator,shall sign in the space provided This signature certifies that the signer is familiar with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information it is the signer's belief that the submitted information is true, accurate and complete 137 TITLE OF SIGNER-Enter the title of the person signing the page UPCF Rev. (12/2007)-2/2 www.unidocs.org