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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION,PAGE 2 <br /> LOCALLY COLLECTED INFORMATION <br /> (04/05/2010-08:51:43 AM) <br /> TYPEOF <br /> 131®Single Owner ❑Partnership T FFED SITE <br /> NETWORK <br /> ORGANIZATION <br /> ❑Corporation El Public Agency NO <br /> ASSESSOR PARCEL NUMBER 140 NEAREST CROSS STREET 141 <br /> 051.060-30 BRUELLA <br /> PROPERTY OWNER NAME(If different from Business Owner) 142 PHONE NO. 143 <br /> BILL BRAUN 209-603-8979 <br /> PROPERTY OWNER STREET ADDRESS 144 PROPERTY OWNER CITY 145 STATE 146 ZIPCODE 147 <br /> 8832 E.HWY 12 VICTOR CA 95253 <br /> FIRE DISTRICT NAME 148IFIRE DEPT NO. 14 FACILITY LOCK BOX IS IF YES,WHERE IS IT LOCATED? 151 <br /> MOKELUMNE FD 13 NO <br /> NATURE OF BUSINESS 152 <br /> WELDING REPAIR SHOP <br /> WASTE GENERATOR 153 1 IF YES,ENTER EPA NUMBER 154 <br /> YES 3241781 <br /> TRADE SECRET INFORMATION 155 SPILL PREVENTION AND COUNTERMEASURES PLAN PREPARED FOR FACILITY? 156 <br /> NO YES <br /> TRAINING PROGRAM INFORMATION 157 <br /> Does your business have an employee training program that includes initial training and annual refreshers? NO <br /> Does your business maintain written training records that show the training subject,date(s)of training, NO <br /> names and signatures of employees trained,and names of instructor(s)? <br /> BILLING ADDRESS If different from Mailing Address,otherwise leave blank <br /> BUSINESS BILLING ADDRESS 158 <br /> P.O.BOX 726 <br /> BUSINESS BILLING CITY 159 STATE 160 ZIP CODE 161 <br /> VICTOR CA 95253 <br /> This area intentionally left blank <br />