Laserfiche WebLink
BUSINESS OWNER/OPERATOR IDENTIFICATION PAGE Page 2 <br /> BUSINESS MAILING AND BILLING INFORMATION <br /> MAILING ADDRESS <br /> If different from Site Address, <br /> otherwise leave blank 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) �= P.O. BOX 8896 <br /> If different from Mailing <br /> Address,otherwise leave blank Street No. Direction Street Name Street Type <br /> 5TOCKTON CA 95208 <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) 117920001 <br /> PROPERTY OWNER (46) HIAAM JEWART PHONE NO. (47) 209-931-1703 <br /> NAME <br /> (If different from Business Owner) <br /> PROPERTY OWNER (48) <br /> ADDRESS 11200 N HWY 99 <br /> Street Address <br /> LODI CA 95240 <br /> CITY STATE ZIP <br /> FIRE DISTRICT NO. 18 FIRE DISTRICT (49) <br /> NAME IMONTEZUMA <br /> NEAREST CROSS (50) <br /> STREET MARIPOSA RD <br /> FACILITY (51) NO IF YES, N/A <br /> LOCK BOX WHERE IS IT LOCATED?(52) <br /> NATURE OF BUSINESS (53) REFRIGERATION REPAIR <br /> WASTE GENERATOR (54) YES IF YES, <br /> WHAT IS YOUR EPA NO.?(55) N/A <br /> TRADE SECRET (56) SPILL 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 /> names and signatures of employees trained,and names of instructor(s)? <br /> DATE REC'D: <br />