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BUSINESS OWNER/OPEIfATOR IDENTIFICATION FORM` I SIDE 2 <br />1 BUSINESS MAILING AND BILLING INFORMATION <br />MAILIN Q� S (�) 11F <br />(If differeH8mr ite gdq(V{) I 1 lei <br />NOTE: YJ Street No. Direction Street Name Street Type <br />officise hip t will <br />be <br />be sent to this address <br />CITY STATE ZIP <br />BILLING ADDRESS (42) <br />If different from above,=AM <br />include "Care of information <br />TYPE OFSingle Owner L]Partnership I UNSTAFFED SITE NETWORK (44) ❑YES �NO <br />ORGANIZATION (43) ❑ Corporation ❑ Public Agency <br />ASSESSOR PARCEL NO. (45) <br />M I41 -:5u <br />PROPERTY OWNER (46)'^ PHONE NO. (47) <br />NAME Ronald � f I n K� 0 t) 311 -22 <br />(If different from Business Owner) <br />PROPERTY OWNER (48) <br />ADDRESS <br />ZU 121 N . -Iwy qq <br />Street Address <br />kam o I F c1522C <br />CITY STATE ZIP <br />FIRE DISTRICT (49) <br />FFor(mt <br />Oil V z <br />LnKC <br />/7 <br />fire <br />apt <br />NEAREST CROSS (50) <br />STREET <br />C'o 111cr Rd 4 .N w qq <br />FACILITY (51) IF YES, <br />LOCK BOX ❑YES NNO WHERE IS IT LOCATED? (52) <br />NATURE OF BUSINESS (53) <br />Aute Vz y - <br />WASTE GENERATOR (54) t—prIF YES, <br />YES ❑NO WHAT IS YOUR EPA NO.? (55) <br />TRADE SECRET (56) ^SPILL PREVENTION (57) <br />INFORMATION V 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) ®YES ❑NO <br />Does your business maintain written training records that show the training subject, date(s) of training, (#) <br />names and signatures of employees trained, and names of instructor(s)?ES , X O <br />12/00 <br />