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BUSINESS OWNER/OPERATG,c IDENTIIG 1TIQN I4QR11I .;i..., Account#: 10097 <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4) CHILI'S GRILL & BAR BUSINESS PHONE(5) 209-474-9004 <br /> SITE ADDRESS (6) 5756 ❑ PACIFIC AVE <br /> Street No. Drrec[ion Street Name Street Type Apt/Bldg/Suite <br /> CITY (7) STOCKTON STATE(8) CA ZIP(9) 95207 <br /> DUN& (10) 197826597 SIC CODE(4 DIGIT#)(11) N/A <br /> BRADSTREET <br /> OPERATOR (12)BRINKER INT OPERATOR PHONE(13) 972-780-9917 <br /> NAME <br /> II.BUSINESS OWNER <br /> OWNER NAME(14) BRINKER INT OWNER PHONE(15) 972-780-9917 <br /> OWNER MAILING ADDRESS(16) 6820 LBJ FREEWAY <br /> (If different from site address) <br /> CITY(17) DALLAS STATE(18) TX Z>P(19) 75240 <br /> III. ENVIRONWNTAL CONTACT <br /> CONTACT NAME(20) GREG AZAVEDO CONTACT PHONE(21) 209-477-0779 <br /> MAILING ADDRESS (22) <br /> (If different from business 2930 DRIFTWOOD PLACE #85 <br /> mailing address) <br /> Street No. Direction Street NameStreet T pe Apt/Bldg/Suite <br /> CITY(23) FOCKTON STATE(24) E <br /> ZIP(25) 95209 <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NAME(3 1)JIM DAMS [GREG AZEVEDO <br /> TITLE(27) AREA DIRECTOR TITLE(32) GEN MGR <br /> BUSINESS PHONE(28) 916- 663-6136 BUSINESS PHONE(33) 209-474-9004 <br /> 24-HOUR PHONE(29) 916-663-6136 24-HOUR PHONE(34) 209-477-0779 <br /> PAGER#(30) N/A PAGER#(35) N/A <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) NQ If yes,and above Threshold Planning Quantities,attach a sheet of paper with a general <br /> description of the process and principle equipment involving the EHS. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION(37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER(38) JOHN SHINER <br /> NAME OF OWNERIOPERATOR(39) BRINKER INT'L DATE(40) <br /> DATE REC'D: 1/12/05 <br />