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State of California—California Environmentaletion Agency �77-454-4012(Calif.Callers Only Toll Free): <br /> Department of Toxic Substances Control(DT or 1-916-255-4439(Outside CaR.) <br /> P.O.Box 1288,Sacramento,CA 95812-1288 www.dtsc.ca.gm <br /> 2010 EPA ID NUMBER VERIFICATION QUESTIONNAIRE <br /> Return within 30 days to avoid suspension of your EPA ID Number. See Instructions on back. <br /> IMPORTANT—If you are a new owner and this is a California EPA ID Number(CAL and some CAD prefixes)that belonged to the <br /> previous owner,do not enter new information on this form. Please contact our office. <br /> Please type or print clearly and use only standard abbreviations, <br /> Mailing Address: If no change,please leave blank. <br /> Address: <br /> TOWER PARK RESORT <br /> 14900 W HIGHWAY 12 City/State/Zip: <br /> LODI CA 95242-9325 <br /> DQ{NQt IIVIIT `II 'FIiS Bfl If the Informatloft in tfiis box is Incorrnct,'call877),'454'o4012 <br /> 1 EPA ICYNUI(/1$ER` CAL000319999 <br /> 5 < aN <br /> 2 LQCATIDN ADDRI S9 14900 WH IG HWAY 12 <br /> V LORI CA 95242 9325, y x <br /> �� X d'2 Y S -^ 4 5 •� fi `• ' i { 1�•� : Y � "'•2 <br /> w,,> It your".Ciu§inesSI has moVedanew EPA1D Number is require d: See mstrucfions tin back <br /> 3. FEDERAL EMPLOYER ID NUMBER(FEIN)REQUIRED: (Also called a Federal Tax ID.)Y <br /> If you do not have a Federal Employer Identification Number,please provide your Social Security Number. <br /> 4. BOARD OF EQUALIZATION NUMBER(BOE): (REQUIRED ONLY IF <br /> GENERATING 5 OR MORE TONS OF HAZ WASTE PER YEAR) <br /> 5. COMPANY OWNER INFO: Company Owner Info Change: If no change, please leave blank. <br /> Owner or Corp. Name: <br /> KAMPGROUNDS OF AMERICA ❑ Name Change Only <br /> 14900 W HIGHWAY 12 ❑ Ownership Change' Date of Ownership Change': <br /> LODI CA 95242-9325 <br /> (209)369-1041 Address: <br /> (209)369-1317 City/State/Zip: <br /> Telephone: Fax: <br /> Federal EPA ID Numbers Only. California EPA ID Numbers are not transferable. <br /> 6. ❑ CHECK TO CANCEL THE EPA ID NUMBER SHOWN ON LINE 1. ID NUMBER WILL BE CANCELED EFFECTIVE 6/30/2010. <br /> If you checked this box in prior year(s)and did not manifest in 2009, please contact our office. (See back for more info.) <br /> 7. COMPANY NAME: Company dA TdR�cQr <br /> Nameohange: If no change, please leave blank. <br /> TOWER PARK RESORT lc '�ti^1jy <br /> 8. CONTACT INFO: Contact Info Change: If no change,please leave blank. <br /> SHERRI KEYS Name/Title: <br /> 14900 W HIGHWAY 12 Address: <br /> LODI CA 95242-9325 <br /> (209)369-1041 City/State/Zip: <br /> (209)369-1317 Telephone:�ZOQ ) 3�$--+Vll Fax: <br /> TPREGION@AOL.COM <br /> Business Email Address: <br /> 9. SIC CODE(4 digits): If printed SIC Code is incorrect, please enter correct Code. <br /> 0000 See instructions on back for SIC Code information. <br /> 10. 1 hereby certify underpenalty of per ury��t�h//ppt the info mation above and on the f'qj e forms is truq ant rect. r <br /> Name(please f y�� G*' � �� Title: <br /> Sign Ure � Date: �vv� .2,2. 2Q/d <br /> DTSC 11 MOK <br /> 15618 t <br /> 0/0 <br />