Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION,PAGE 2 <br /> LOCALLY COLLECTED INFORMATION <br /> (05/24/2011- 04:34:20 PM) <br /> TYPE OF 13 UNSTAFFED SITE NETWORK <br /> ORGANIZATION ❑Single Owner ❑Partnership <br /> N Corporation ❑Public Agency NO <br /> ASSESSOR PARCEL NUMBER 140 NEAREST CROSS STREET 141 <br /> 221-040-05 LUPTON-WAWONA <br /> PROPERTY OWNER NAME(If different from Business Owner) 142 PHONE NO. 143 <br /> DON AND ELLEN SALMON 209-824.4412 <br /> PROPERTY OWNER STREET ADDRESS 144 1 PROPERTY OWNER 3177-111-453[S-TATE 146 ZIPCODE 147 <br /> 1830 E YOSEMITE AVE SPACE#194 MANTECA CA 95336 <br /> FIRE DISTRICT NAME 14 FIRE DEPT NO. 14 FACILITY LOCK BOX 151117 YES,WHERE IS IT LOCATED? 151 <br /> MANTECA FD 24 NO <br /> NATURE OF BUSINESS 152 <br /> EQUIPMENT RENTAL YARD <br /> WASTE GENERATOR 153 1 IF YES,ENTER EPA NUMBER 154 <br /> NO NA <br /> TRADE SECRET INFORMATION 155 SPILL PREVENTION AND COUNTERMEASURES PLAN PREPARED FOR FACILITY? 156 <br /> NO NO <br /> TRAINING PROGRAM INFORMATION 157 <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 BILLING CITY 159 STATE 160 ZIP CODE 161 <br /> This area intentionally left blank <br />