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RECEIVE® <br /> UNIFIED PROGRAMCONSOLIDATEFACILITY INFORMATION D FORM MAY 2 1 20cq <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION,PAGE 2 <br /> LOCALLY COLLECTED INFORMATION SAN JOAQUIN COU qTy <br /> (05/05/2009-08:24:10 AM) OFFICE OF EMERGENCY ERVICES <br /> TYPE OF ❑Single Owner ❑Partnership 138 UNSTAFFED SITE NETWORK 139 <br /> ORGANIZATION <br /> ®Corporation ❑Public Agency YES <br /> ASSESSOR PARCEL NUMBER 140 NEAREST CROSS STREET 141 <br /> 255-090-58&59 HW <br /> Y 132 <br /> PROPERTY OWNER NAME(If different from Business Owner) 142 1 PHONE NO. 143 <br /> SCOTT&MARTY BEDFORD XXX <br /> PROPERTY OWNER STREET ADDRESS 144 PROPERTY OWNER CITY 145 STATE 146 ZIP CODE 147 <br /> 125 RYAN INDUSTRIAL COURT,#109 SAN RAMI CA 94583 <br /> FIRE DISTRICT NAME 148 FIRE DEPT NO.149 FACILITY LOCK BOX 15011F YES,WHERE IS IT LOCATED? I S 1 <br /> TRACY RURAL FIRE XXX NO N/A <br /> NATURE OF BUSINESS 12 <br /> TELECOMMUNICATIONS <br /> WASTE GENERATOR 153 1 IF YES,ENTER EPA NUMBER 1>4 <br /> NO N/A <br /> TRADE SECRET INFORMATION 155 SPILL PREVENTION AND COUNTERMEASURES PLAN PREPARED FOR FACILITY? I <br /> NO NO <br /> TRAINING PROGRAM INFORMATION I S7 <br /> Does your business have an employee training program that includes initial training and annual refreshers? YES <br /> Does your business maintain written training records that show the training subject,date(s)of training, YES <br /> names and signatures of employees trained,and names of instructor(s)? <br /> BILLING ADDRESS If different from Mailing Address,otherwise leave blank <br /> BUSINESS BILLING ADDRESS 158 <br /> BUSINESS BILLLING CITY 159 STATE 160 ZIP CODE 161 <br /> This area intentionally left blank <br />