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LIAR 18 2004 <br />BUSINESS OWNER/OPER�OR IDENTIFICATION PAGE Page 2 <br />ASSESSOR PARCEL NO. (45) <br />PROPERTY OWNER (46) TOM SAUREY PHONE NO. (47) <br />NAME <br />(If different from Business Owner) <br />PROPERTY OWNER (48) <br />ADDRESS <br />CITY STATE ZII' <br />FIRE DISTRICT NO. FIRE DISTRICT (49) <br />NAME IMONTAZUMA <br />NEAREST CROSS (50) FRONTAGE & LOOMIS <br />STREET <br />LOCK <br />(51) IF YES, <br />LOCK BOX WHERE IS IT LOCATED? (52) <br />NATURE OF BUSINESS (53) <br />PREFAB STORAGE SHEDS <br />WASTE GENERATOR (54) NO IF YES, <br />WHAT IS YOUR EPA NO.? (55) <br />TRADE SECRET (56)SPILL PREVENTION (57) <br />INFORMATION AND COUNTERMEASURES YES <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 />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)? <br />DATE REC' D: 3 /18 / 0 4 <br />BUSINESS MAILING AND BILLING INFORMATION <br />MAILING ADDRESS (41) <br />If different from Site Address, <br />otherwise leave blank <br />Street No. Direction Street Name Street Type <br />NOTE: All official mail <br />will go to this address <br />City State ZIP <br />BILLING ADDRESS (42) <br />If different from Mailing <br />Address, otherwise leave blank Street No. Direction Street Name Street Type <br />�I <br />City State ZIP <br />ADDITIONAL BUSINESS INFORMATION <br />TYPE OF <br />❑ Single Owner ❑ Partnership UNSTAFFED SITE <br />ORGANIZATION (43) <br />® Corporation ❑ Public Agency NETWORK (44) <br />ASSESSOR PARCEL NO. (45) <br />PROPERTY OWNER (46) TOM SAUREY PHONE NO. (47) <br />NAME <br />(If different from Business Owner) <br />PROPERTY OWNER (48) <br />ADDRESS <br />CITY STATE ZII' <br />FIRE DISTRICT NO. FIRE DISTRICT (49) <br />NAME IMONTAZUMA <br />NEAREST CROSS (50) FRONTAGE & LOOMIS <br />STREET <br />LOCK <br />(51) IF YES, <br />LOCK BOX WHERE IS IT LOCATED? (52) <br />NATURE OF BUSINESS (53) <br />PREFAB STORAGE SHEDS <br />WASTE GENERATOR (54) NO IF YES, <br />WHAT IS YOUR EPA NO.? (55) <br />TRADE SECRET (56)SPILL PREVENTION (57) <br />INFORMATION AND COUNTERMEASURES YES <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 />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)? <br />DATE REC' D: 3 /18 / 0 4 <br />