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BUSINESS OWNER/OPERATOR IDENTIFICATION FORM SIDE 2 <br /> MAIL <br /> REQW SS"�p BUSI AND BILLING INFORMATION <br /> (If different from Site� ss) 200 <br /> NOTE: r@lEt{mt1s�tsiM 9nd Street No. 1 ipn Street Name Street <br /> official corres �I t�ty SER <br /> be s Cy SERN S t;RCE N EMEiGEN <br /> CITY STATE ZIP <br /> BILLING ADDRESS(42) <br /> If different from above, <br /> include"Care of information r (, rile tt rr t <br /> �0 60 //3 X/oclke{ord 95 37 <br /> ADDITIONAL BUSINESS INFORMATION <br /> TYPE OFELI Single Owner ❑Partnership UNSTAFFED SITE NETWORK(44) <br /> ORGANIZATION (43) Corporation ❑Public Agency ❑Y[iS No <br /> ASSESSOR PARCEL NO. (45) <br /> c. v <br /> PROPERTY OWNER (46) //�� PHONE NO."(4,7) <br /> NAME ✓7.'f?�S lel �(jC' UIYIvl' 7a7��rb <br /> (If different from Business Owner) <br /> PROPERTY OWNER (48) 1 /J n <br /> ADDRESS NZ /M�vn 1/3 <br /> ��Kttlll Street Address <br /> �ocl<Eo�t'd� -3 <br /> CITY STATE Zill <br /> FIRE DISTRICT (49) <br /> It -1 <br /> e <br /> Jt4Mn <br /> e ire. <br /> NEAREST CROSS (50) Fe, <br /> STREET �Z,d-� <br /> FACILITY (51) O IF YES, <br /> LOCK BOX ❑YES �NO WHERE IS IT LOCATED?(52) <br /> NATURE OF BUSINESS (53) <br /> Drll/ 'Cck17� rl�lnPum s <br /> WASTE GENERATOR (54) IF YES, <br /> pIYES ❑NO WHAT IS YOUR EPA NO.?(55)TRADE SECRET <br /> Rb 9817S�J <br /> INFORMATION 156) ('ID SPILL PREVENTIO�AND COUNTERMEASURES57) 1 r� <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 /> 12/00 <br />