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Am <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION PAGE Page 2 <br /> BUSINESS MAILING AND BILLING INFORMATION <br /> MAILING ADDRESS �= P.O.BOX 726 <br /> If different from Site Address, <br /> otherwise leave blank Street No. Direction Street Name Street Type <br /> NOTE: All official mail VICTOR CA 95253 <br /> will go to this address <br /> City State ZIP <br /> BILLING ADDRESS(42) <br /> If <br /> P.O.BOX 726 <br /> If different from Mailing <br /> IF <br /> Address,otherwise leave blank Street No. Direction Street Name Street Type <br /> VICTOR CA 95253 <br /> City State ZIP _ <br /> ADDITIONAL BUSINESS INFORMATION <br /> TYPE OF ®Single Owner ❑Partnership UNSTAFFED SITE NO <br /> ORGANIZATION(43) ❑Corporation [I Public Agency NETWORK(44) <br /> ASSESSOR PARCEL NO. (45) 1051-060-30 <br /> PROPERTY OWNER (46) PHONE NO. (47) 209-365-9416 <br /> NAME BILL BRAUN <br /> (If different from Business Owner) <br /> PROPERTY OWNER (48) <br /> ADDRESS 111798 BENDORF RD. <br /> Street Address <br /> ACAMPO CA 95220 <br /> CITY STATE ZIP <br /> FIRE DISTRICT NO. 13 FIRE DISTRICT (49) <br /> NAME MOKELUMNE FD <br /> NEAREST CROSS (50)STREET Fi��LLA <br /> FACILITY (51) NO IF YES, <br /> LOCKBOX WHERE IS IT LOCATED?(52) <br /> NATURE OF BUSINESS (53) WELDING REPAIR SHOP <br /> WASTE GENERATOR (54) YES IF YES, <br /> WHAT IS YOUR EPA NO.?(55) 3241781 <br /> TRADE SECRET (56) ANSPILL PREVENTION (57) <br /> INFORMATION NO AND COUNTERMEASURES YES <br /> PLAN FOR THIS FACILITY <br /> TRAINING PROGRAM INFORMATION <br /> Does your business have an employee training program that includes initial training and annual refreshers? (58) NO <br /> Does your business maintain written training records that show the training subject,date(s)of training, (59) NO <br /> names and signatures of employees trained,and names of instructor(s)? <br /> DATEREC'D: 1/28/08 <br />