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UNIFIED PROGRAM CONSOLIDATED FORM <br />FACILITY INFORMATION <br />BUSINESS OWNER/OPERATOR IDENTIFICATION, PAGE 2 <br />LOCALLY COLLECTED INFORMATION <br />(07/30/2009 - 03:19:30 PM) <br />TYPE OF I <br />ORGANIZATION ❑ Single Owner ❑ Partnership <br />UNSTAFFED SITE NETWORK <br />139 <br />® Corporation ❑ Public Agency <br />NO <br />ASSESSOR PARCEL NUMBER 140 <br />NEAREST CROSS STREET <br />I ! I <br />209-080-06 <br />1-205 <br />PROPERTY OWNER NAME (If different from Business Owner) 142 <br />PHONE NO. <br />1.13 <br />N/A <br />N/A <br />1 <br />PROPERTY OWNER STREET ADDRESS 144 <br />PROPERTY OWNER CITY 145 <br />STATE 146 <br />ZIP CODE <br />1 !7 <br />N/A <br />N/A <br />N/A <br />N/A <br />FIRE DISTRICT NAME 148 <br />FIRE DEPT NO. 149 <br />1,%('ILTTY LOCK BOX 1501F <br />YES, WHERE IS IT LOCATED? <br />15 t <br />TRACY FIRE <br />N/A <br />YES <br />NEXT TO SOUTH GATE <br />NATURE OF BUSINESS <br />152 <br />GAS SUPPLY UTILITY <br />WASTE GENERATOR 153 <br />IF YES. ENTER EPA NUMBER <br />154 <br />YES <br />CAD981163298 <br />1 <br />TRADE SECRET INFORMATION 155 <br />SPILL PREVENTION AND COUNTERMEASURES PLAN PREPARED FOR FACILITY? <br />156 <br />NO <br />NO <br />TRAINING PROGRAM INFORMATION <br />1>7 <br />Does your business have an employee training program that includes initial training and annual refreshers? YES <br />Does your business maintain written training records that show the training subject, date(s) of training. YES <br />names and signatures of employees trained, and names of instructor(s)? <br />BILLING ADDRESS If different from Mailing Address, otherNise leave blank <br />BUSINESS BILLING ADDRESS <br />158 <br />P.O. BOX 106 <br />BUSINESS BILLLING CITY 159 <br />STATE 160 <br />ZIP CODE <br />161 <br />HOLT <br />CA <br />95234 <br />This area intentional1v left blank <br />