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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION,PAGE 2 <br /> LOCALLY COLLECTED INFORMATION <br /> (05/07/2009- 10:34:03 AM) <br /> TYPE OF 138 UNSTAFFED SITE NETWORK I39 <br /> ORGANIZATION ®Single Owner ❑Partnership <br /> ❑Corporation ❑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 1 PHONE NO. 143 <br /> BILL BRAUN 209-365-9416 <br /> PROPERTY OWNER STREET ADDRESS 144 PROPERTY OWNER CTTY 145 STATE 146 ZIP CODE 147 <br /> 8832 E.HWY 12 VICTOR CA 95253 <br /> FIRE DISTRICT NAME 148 FIRE DEPT NO.149 FACILITY LOCK BOX 150 IF YES,WHERE IS IT LOCATED? 151 <br /> MOKELUMNEFD 13 NO <br /> NATURE OF BUSINESS 152 <br /> WELDING REPAIR SHOP <br /> WASTE GENERATOR 153 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,datc(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 />