HomeMy WebLinkAbout1101 Laurel UST docs·----. \
FACILITY INFORMATION
BUSINESS NAME
DEPT/DIV
STREET ADDRESS
CITY
CROSS STREET
INDUSTRY CLASS (SIC CODE)
FACILITY ID NO.
NATURE OF BUSINESS
EPA. ID NO.
OWNER �e..� '),fq,.f.:--dL
STREET }Jo) k\('C. \ k-->-
CITY S L--0 STATE CdL_
STATE ZIP CODE C, 3L/O)
DUN & BRADSTREET
- .. ------·---•EMERGENCY CONTACTS·.,. .. - - -...... -�-- - -- ....
1
NAME PHONE
NAME PHONE
TITLE 24-HR PHONE
TITLE 24-HR PHONE
LAST UPDATE
EMERGENCY PLANNING INFORMATION
Name of Facility Coordinator if diff erent from above
For State/Fed Planning: We handle extremely hazardous substances listed in 40 CFR 355,
Appendix A yes no
There are school(s)/hospital(s)/ extended care facilities within
1,000 ft. (straight line distance) of my facility. ( ] ( J yes no
CERTIFICATION: I certify under penalty of law that I have personally examined and I am familiar with the inf�rmation submitted and believe the information is true, accurate and complete.
Print Name of owner/Operator :::Ye-FF 'S fGVA-cL,
Print Name of Document preparer 0-&FF 5-f>GYtk-lL
Signature of Owner/Operator =74Y1P�Date 1.:i -1 � 'j.2 ..
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