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' .. ' 0 • p rn% nn,7 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />FACILITY ITY INFORMATION <br />BUSINESS OWNER/OPERATOR IDENTIFICATION, PAGE 2 <br />LOCALLY COLLECTED INFORMATION <br />TYPE OF13 <br />El Single Owner El Corporation El Partnership <br />TINCTAFFFT)CTTRNRTW0RK <br />139 <br />Jnr *r 7AT �*r <br />YES <br />ASSESSOR PARCFI.NTIMRPR 140 <br />NEAREST CROSS STREET <br />141 <br />005-170-07 <br />PELTIER & JAHANT <br />PROPERTY OWNER NAME (If different from Business Owner) 142 <br />PHONE NO. <br />143 <br />ROBERT E & CYNTHIA J KUPKA <br />209-369-9126 <br />PROPERTY OWNER STREET ADDRESS 144 <br />PROPERTY OWNER CITY 145 <br />STATE 146 <br />ZIP CODE <br />147 <br />P.O. BOX 10 <br />ACAMPO <br />CA <br />95220 <br />FIRE DISTRICT NAME 148 <br />FIRE DEPT NO. 14 <br />FACILITY LOCK BOX 15 <br />IF YES, WHERE IS IT LOCATED? <br />151 <br />WOODBRIDGE FD <br />7 <br />I NO <br />NATT TRF nF RT TSTNFSS <br />152 <br />NATURAL GAS TRANSMISSION AND STORAGE <br />WASTE GENERATOR 153 <br />IF YES. ENTER EPA NUMBER <br />154 <br />YES <br />CAL000230279 <br />TR ADF. SFPRFT TNFORMATInN 155 <br />SPILL PREVENTION AND COI INTF.RMEASURES PLAN PREPARED FOR FACILITY? <br />156 <br />NO <br />YES <br />TRAINING PROGRAM INFORMATION <br />157 <br />U-.:_ :,. _ :_:.: , :: _ _ : ....9 YES <br />Does your business maintain written training records that show the training subject, date(s) of training, YES <br />RIT.LINf_ AnnRRCR If diff nrnnt frnm Mvnino Adduct. nthpr ki Irnvr hlanh <br />BUSINESS BILLING ADDRESS <br />158 <br />BUSINESS BILLING CITY 159 <br />STATE 160 <br />ZIP CODE <br />161 <br />This area intentionally left blank <br />