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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION, PAGE 2 <br /> LOCALLY COLLECTED INFORMATION <br /> TYPE OF l3 T FNSTAFFFD CTTF NFTWORK <br /> L1 Single Owner El Corporation ®Partnership 139 <br /> NO <br /> ASSFSROR PARCFT.NT TMRFR 140 NEAREST CROSS STREET 141 <br /> 7240 JACK TONE RD <br /> PROPERTY OWNER NAME(If different from Business Owner) 142 PHONE NO. 143 <br /> GEORGE GALATSATOS 209-368-9834 <br /> PROPERTY OWNER STREET ADDRESS 144 1 PROPERTY OWNER CITY 145 STATE 146 ZIP CODE 147 <br /> 18662 N HIGHWAY 88 LOCKEFORD CA 95237 <br /> FIRE DISTRICT NAME 14 FIRE DEPT NO. 14 FACILITY LOCK BOX 15 IF YES,WHERE IS IT LOCATED? 151 <br /> MOKELUMNE 13 NO �N/A <br /> NATT FRF OF RI FCINFCC 152 <br /> GAS&MINI MART <br /> WASTE GENERATOR 153 IF YES.ENTER EPA NUMBER 154 <br /> YES CAL000287525 <br /> TR ADF SFCRFT INFORMATION 155 SPILL PREVENTION AND COT TNTFRMEASURES PLAN PREPARED FOR FACILITY? 156 <br /> NO YES <br /> TRAINING PROGRAM INFORMATION 157 <br /> _.,.... YES <br /> Does your business maintain written training records that show the training subject,date(s)of training, YES <br /> RTU].T NG ADnRFSS 1fdiffcrcnf frnm Mailino Addrracc. nfhrrwicn Iravr hlan4 <br /> BUSINESS BILLING ADDRESS 158 <br /> BUSINESS BILLING CITY 159 STATE 160 ZIP CODE 161 <br /> This area intentionally left blank <br />