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BUSINESS OWNER/OPERATOR IDENTIFICATION PAGE Page 2 <br /> BUSINESS MAILING AND BILLING INFORMATION <br /> MAILING ADDRESS(41) 4460 HWY 99 FRONTAGE RD <br /> If different from Site Address, <br /> 11 <br /> otherwise leave blank Street No. Direction Street Name Street Type <br /> NOTE: All official mail STOCKTON CA 95215 <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 /> City State ZIP <br /> ADDITIONAL BUSINESS INFORMATION <br /> TYPE OF ❑Single Owner N Partnership UNSTAFFED SITE YES <br /> ORGANIZATION(43) ❑Corporation ❑Public Agency NETWORK(44) <br /> ASSESSOR PARCEL NO. (45) 1179-172-38 <br /> PROPERTY OWNER (46) BAL USC PHONE NO. (47) <br /> NAME 209-932-0606 <br /> (If different from Business Owner) <br /> PROPERTY OWNER (48) <br /> ADDRESS 14236 S.FRONTAGE RD., HWY 99 <br /> Street Address <br /> STOCKTON CA 95215 <br /> CITY STATE ZIP <br /> FIRE DISTRICT NO. 18 FIRE DISTRICT (49) <br /> NAME IMONTEZUMA <br /> NEAREST CROSS (50) MARIPOSA <br /> STREET <br /> FACILITY (51) NO IF YES, N/A <br /> LOCK BOX WHERE IS IT LOCATED. (52) <br /> NATURE OF BUSINESS (53) VARIOUS <br /> WASTE GENERATOR (54) NO IF YES. N/A <br /> WHAT IS YOUR EPA NO.. (55) <br /> TRADE SECRET (56) D SPII L PREVENTION (57) <br /> INFORMATION NO 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) YES <br /> Does your business maintain written training records that show the training subject,date(s)of training, (59) YES <br /> names and signatures of employees trained,and names of instructor(s)? <br /> DATE REC'D: 5/11/05 <br />