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BUSINESS OWNER/OPEW -OR IDENTIFICATION FORM SIDE 2 <br /> EdEF- __ BUSINESS MAILING AND BILLING INFORMATION <br /> MAILINGE <br /> (I£diffenMt;t;#q{7iltgAddreress) <br /> NSM'j 0� land Street No. Direction Street Name Street Type <br /> OtE pF <br /> be sent to this ad�VICES �•T l �� <br /> ,RECEIVED CITY STATE ZIP <br /> BILLING ADDRESS(42) <br /> If differeAWrQa§bvM5 <br /> includeSAN55/PGNIWn <br /> OFFICE OF EMERGENCY SERVICE <br /> EIVED ADDITIONAL BUSINESS INFORMATION <br /> TYpl' Single Owner ❑Partnership UNSTAFFED SITE NETWORK <br /> ORC�(ZA77Qhy,,� (43) Corporation ❑Public Agency (44) YES NO <br /> �c��1ftW LLMN� OS(45) <br /> �rn�c yr t <br /> PROPERTY OWNER (46) PHONE NO. (47) <br /> NAME f !�� <br /> (If different from Business Owner) <br /> PROPERTY OW* `_ (48) <br /> ADDRESS J �� <br /> Street Address <br /> CITY STATE ZIP <br /> FIRE DISTRICT (49) <br /> NEAREST CROSS (50) <br /> STREET FACILITY . [I <br /> LOCK BOX (51) YES Sf'r.O IyIN IF YES, <br /> WHERE IS IT LOCATED?(52) <br /> NATURE OF BUSINESS (53) <br /> / ! r <br /> WASTE GENERATOR (54) IF YES, <br /> YES ❑NO WHAT IS YOUR EPA NO.?(55) <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) <br /> 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 />