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AL Ak <br /> BUSINESS OWNER PER OR IDENTIFICATION PAGE Page 2 <br /> BUSINESS MAILING AND BILLING INFORMATION <br /> MAILING ADDRESS(41) 1= <br /> 1 11 1 <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 Slate 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 ❑Partnership UNSTAFFED SITE NO <br /> ORGANIZATION(43) ®Corporation ❑Public Agency NETWORK(44) <br /> ASSESSOR PARCEL NO. (45) IAAN#58653-5 APN#10227006 <br /> PROPERTY OWNER (46) N/A PHONE NO. (47) N/A <br /> NAME <br /> (If different from Business Owner) <br /> PROPERTY OWNER (48) N/A <br /> ADDRESS <br /> Street Address <br /> N/A N/A N/A <br /> CITY STATE ZIP <br /> FIRE DISTRICT NO. 22 FIRE DISTRICT (49) <br /> NAME ISTOCKTON FD <br /> NEAREST CROSS (50) BIlVHOOD <br /> STREET RO <br /> FACILITY (51) NO IF YES' N/A <br /> LOCK BOX WHERE IS IT LOCATED?(52) <br /> NATURE OF BUSINESS (53) RESTAURANT <br /> WASTE GENERATOR (54) NO IF YES, <br /> WHAT IS YOUR EPA NO.?(55) N/A <br /> TRADE SECRET (56) D SPILL PREVENTION (57) <br /> INFORMATION NO AND COUNTERMEASURES NO <br /> PLAN FOR TIES 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: 1/12/05 <br />