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Mas 10 02 11357a San Jeequln DES 209-468-21300 .(Alr 1 'a p43 <br /> BUSINESS OWNERIOPERATOR IDENTIFICATION FORM SIDE 2 <br /> BUSINESS MAILING AND RILIANG INFORMATION <br /> MAILING ADDRESS(41ite Add ) �.7� �/tel FIL - <br /> (,iFAifferenttromSiteAtldnris) erect <br /> NOTE: Ali time sensitive and tree"No. rccnun Street Naurc �Yr- <br /> offrcialeorteaponsience wiltSn L(CT � /'4 �S7 <br /> he sent to Ink address C• <br /> CITY STATE LIP <br /> BILLING ADURBSS(42) <br /> It different frsnl above, <br /> include"Care of"Information <br /> D ITIONAL BU INESS INBORMATI N <br /> TYPO OF Singie Owner U Partnership I UNSTAFFED SITE NGPWORK(44) <br /> ORGANIZATION (43) Rcarporruan ❑Public Agency r" <br /> ASSF330R PARCEL NO.(45) <br /> AAA) 53 -S' /oZa�oo <br /> PROPERTY OWNER (an) r PHON£NO.(47) <br /> NAME <br /> (it different from Business Owner) <br /> PROPERTY OWNER (48) <br /> ADDRESS <br /> Sncvt Addrta <br /> CITY SVNIE Ler <br /> FIRE DISTRICT (49) C OP .fnc/tn.! <br /> NEAREST CROSS (50) <br /> STREF,'r <br /> l51) IF YES, <br /> FACILITY <br /> OYES Nn WHERE IS 1T LOCAYF.D i 1571 <br /> Lock eDx <br /> NAT1JREOF0VStNL•S8 153) <br /> Llf45,,!I <br /> WASTE CENERA'IOK (54) HAT <br /> WJ <br /> OYESiO WHA'('IS YOUR EPA NO 1(53) <br /> TRADL'S£CRL'r t56) SPILL PREVENTION (571 NO <br /> INFORMATION 0 ALD FOR THIS FACILITY PLAN FOR THIS FACILITY <br /> TRAINING GROGRAM INFORMIATION <br /> Dora your businessh>+c an emPluytc training progrnm that includes initial training and annual refreshcrs7 (58) ® Op;O <br /> Does your business maintain written training records diet show the training sub)cc1,datc(s)of"dining, (59) �Y (-7 NO <br /> naiuet and signatures of rmployces treinc 1.and names of in3tnxtor(s)7 11 I`rte <br /> VO 39Vd 9EELTLL9T6 LS 60 Z00Z/ZT/58 <br />