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BUSINESS OWNER/OPERAT"R IDENTIFICATION FORM SIDE 2 <br /> BUSINESS MAILING AND BILLING INFORMATION <br /> c f d vt� <br /> ok&ggl soA14N"PAP(dress) /l ' � 4-J <br /> [R( �fLP.�,ni faiielikisiff aid Street No. Direction Street Name Street Type <br /> official correspondence will <br /> be sent to this address STOCLiI RECEI D <br /> CITY STATE ZIP <br /> BILLING ADDRESS(42) <br /> If different from above, SAN JOAQUIN NIy <br /> include"Care of information <br /> SERVICES <br /> ADDITIONAL BUSINESS INFORMATION <br /> TYPE OF ❑Single Owner ❑Partnership UNSTAFFED SITE NETWORK(44) AYES �NO <br /> ORGANIZATION (43) Corporation ❑Public Agency <br /> ASSESSOR PARCEL NO. (45) <br /> / 5t7 - 3�p- z-! <br /> PROPERTY OWNER (46) PHONE NO. (47) <br /> NAME <br /> (If different from Business Owner) <br /> PROPERTY OWNER (48) <br /> ADDRESS <br /> Street Address <br /> CITY STATE ZIP <br /> FIRE DISTRICT (49) <br /> STo ceT0,J �1 PF J�pT <br /> NEAREST CROSS (50) <br /> STREET 747- eG. PV S� <br /> FACILITY (51) IF YES, <br /> LOCK BOX AYES EVO WHERE IS IT LOCATED?(52) <br /> NATURE OF BUSINESS (53) ,l�'v <br /> 2EPA'1 /G <br /> WASTE GENERATOR (54) IF YES, <br /> YES ❑NO WHAT IS YOUR EPA NO.?(55) L tcoo /DS°J (.� <br /> TRADE SECRET (56) SPILL PREVENTION (57) <br /> INFORMATION AND COUNTERMEASURES <br /> PLAN FOR THIS FACILITY <br /> TRAINING PROGRAM INFORMATION <br /> Does your business have an employee training program that includes initial training and annual refreshers? (58) YES ❑NO <br /> Does your business maintain written training records that show the training subject,date(s)of training, (59)� <br /> names and signatures of employees trained,and names of instructor(s)? YES �NO <br /> 12/03 <br />