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BUSINESS OWNER/OPERAYOR IDENTIFICATION PAGE Page 2 <br />BUSINESS MAILING AND BILLING INFORMATION <br />MAILING ADDRESS (41) 1407 LONE PALM AVE <br />If different from Site Address, <br />otherwise leave blank Street No. Direction Street Name Street Type <br />NOTE: All official mail MODESTO CA 95351 <br />will go to this address <br />City State ZIP <br />BILLING ADDRESS (42) IJ = <br />If different from Mailing <br />Address, otherwise leave blank Street No. Direction Street Name Street Type <br />City State ZIP <br />ADDITIONAL BUSINESS INFORMATION <br />TYPE OF ❑ Single Owner ❑ Partnership UNSTAFFED SITE NO <br />ORGANIZATION (43) ® Corporation ❑ Public Agency NETWORK (44) <br />ASSESSOR PARCEL NO. (45) <br />PROPERTY OWNER (46) PHONE NO. (47) <br />NAME ROEK CONSTRUCTION 209-464-8344 <br />i I <br />(If different from Business Owner) <br />PROPERTY OWNER (48) <br />ADDRESS <br />P.O. BOX 30038 <br />Street Address <br />STOCKTON CA 95213-0038 <br />CITY STATE ZIP <br />FIRE DISTRICT NO. [j;7 <br />8 FIRE DISTRICT (49) <br />NAME IMONTEZUMA <br />NEAREST CROSS (50) <br />STREET <br />RD. <br />FACILITY (51) NO IF YES, <br />LOCK BOX WHERE IS IT LOCATED? (52) <br />NATURE OF BUSINESS (53) TRUCK TIRE RETREADING <br />WASTE GENERATOR (54) YES IF YES, 1124435-01 <br />WHAT IS YOUR EPA NO.? (55) <br />TRADE SECRET (56)D AND PREVENTION (57) <br />INFORMATION NO AND COUNTERMEASURES NO <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 <br />Does your business maintain written training records that show the training subject, date(s) of training, (59) YES <br />[tames and signatures of employees trained, and names of instructor(s)? <br />DATE REC'D: 9/22/04 <br />