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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACHJTV INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION, PAGE 2 <br /> LOCALLY COLLECTED INFORMATION <br /> TYPE OF ❑ Single Owner ❑ Corporation ®Partnership 138 1 TNSTAFFFD S1TF.NFTWnRK 139 <br /> nn n_A ARO A mrnw, YES <br /> A.';cFccnR PARCFT.NTTMRFR 140 NEARESTCROSS STREET 141 <br /> 179-172-38 MARIPOSA <br /> PROPERTY OWNER NAME(If different from Business Owner) 142 1 PHONE NO. 143 <br /> BAL USC 209-932-0606 <br /> PROPERTY OWNER STREET ADDRESS 144 PROPERTY OWNER CITY 145 STATE 146 ZIP CODE 147 <br /> 4460 S.HIGHWAY 99 STOCKTON CA 95215 <br /> FIRE DISTRICT NAME 14 FIRE DEPT NO. 141 FACILITY LOCK BOX 151 IF YES,WHERE IS IT LOCATED? 151 <br /> MONTEZUMA 18 NO N/A <br /> NATI IRF OF RI TSTNF.SS 152 <br /> LEASED SPACE <br /> WASTE GENERATOR 153 IF YES.ENTER EPA NUMBER 154 <br /> NO N/A <br /> TR ADF SFCRFT INFnRMATIf1N I11 SPILL PREVENTION AND COI INTFRMEASURES PLAN PREPARED FOR FACILITY? 156 <br /> NO NO <br /> TRAINING PROGRAM INFORMATION 157 <br /> Does your business maintain written training records that show the training subject,date(s)of training, NO <br /> RII.i.TNR ADDRRRR if diMfr .t frnm Mailing Addr ..nthe kw Inavr hlank <br /> BUSINESS BILLING ADDRESS 158 <br /> 893 BOGGS TERRACE <br /> BUSINESS BILLING CITY 159 STATE 160 ZIP CODE 161 <br /> FREMONT CA 94539 <br /> This area intentionally left blank <br />