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------------ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACIT,TTY TNFORMATTON <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION, PAGE 2 <br /> LOCALLY COLLECTED INFORMATION <br /> TYPE OF <br /> n1 l-AXTT'IATTnXT El Single Owner ® Corporation El Partnership 13 TTN NO <br /> FFFT)STTFNFTWORK 139 <br /> NO <br /> ARSRS.SOR PARCFT.NTIMRFR 140 NEAREST CROSS STREET 141 <br /> 062-510-04 KETTLEMAN <br /> PROPERTY OWNER NAME(If different from Business Owner) 142 PHONE NO. 143 <br /> BILL MAXWELL N/A <br /> PROPERTY OWNER STREET ADDRESS 144 PROPERTY OWNER CITY 145 STATE 146 ZIP CODE 147 <br /> 1129 W WALNUT STREET STOCKTON CA 95203 <br /> FIRE DISTRICT NAME 141r DEPT NO. 1491 FACILITY LOCK BOX 151 IF YES,WHERE IS IT LOCATED? 151 <br /> LODI CITY 20 NO <br /> NATT IRF OF W NTNRSS 152 <br /> AUTO REPAIR <br /> WASTE GENERATOR 153 IF YES.ENTER EPA NUMBER 154 <br /> YES CAL000343853 <br /> TR ADF.SFCRRT TNFT)RMATf0N 155 SPILL PREVENTION AND COT JNTF,RMEASURES PLAN PREPARED FOR FACILITY? 156 <br /> NO YES <br /> TRAINING PROGRAM INFORMATION 157 <br /> .._A YES <br /> Does your business maintain written training records that show the training subject,date(s)of training, YES <br /> ....d,.:........ ..0..................... ....d --d.........--1;---------.-NO <br /> RTLT.1Nf_AnDRF.R.R if diffrranf frnm Mailino Addrrcc.ntharwicr Iwnvr hlon4 <br /> BUSINESS BILLING ADDRESS 158 <br /> BUSINESS BILLING CITY 159 STATE 160 ZIP CODE 161 <br /> This area intentionally left blank <br />