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State of California-California Environmental Protection Agency 1-877-454-4012(Calif.Callers Only Toll Free) <br /> ariment of Toxic Substances Control(DTS ' or 1-916-255-4439(Outside Calif.) <br /> P.O.Boz 1288,Sacramento,CA 95812-1288 • www.dtsc.ca.gov <br /> 2009 VERIFICATION QUESTIONNAIRE <br /> See instructions on back. <br /> ALL FORMS MUST BE RETURNED WITHIN 30 DAYS FROM THE DATE OF RECEIPT. <br /> FAILURE TO RETURN ALL FORMS WILL LEAD TO THE SUSPENSION OF YOUR EPA IDENTIFICATION NUMBER. <br /> Please type or print clearly. Use only standard abbreviations. <br /> TOWER PARK RESORT Mailing Address: If no change,please leave blank. <br /> 14900 W HIGHWAY 12 Address: <br /> LODI,CA 95242-9325 <br /> 1�II'll"II��II�rrI11IJIIIIIIrIIIrInIrIIhI�Illlllllllllullrlr <br /> City/State/Zip: <br /> Y 4 <br /> �LL V 41n a .:51 — 4 '4 Y i.4 � • � �'T ki•�.M. <br /> � <br /> c�`nar6wlG/,'� <br /> 3. FEDERAL EMPLOYER ID NUMBER(FEIN)REQUIRED: ��� (Also called a Federal Tax ID.) <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 GENERATING 5 OR MORE TONS OF <br /> HAZARDOUS WASTE PER YEAR) <br /> THIS SECTION IS FOR UPDATESICHANGES TO U.S.EPA(FEDERAL)ID NUMBERS ONLY <br /> California EPA ID Numbers are NOT transferable to another owner. DO NOT change owner information if you have a California <br /> EPA ID Number(CAL and some CAD prefixes). Check Box 6 to cancel this EPA ID Number and contact our office. <br /> 5. COMPANY OWNER INFO: Date of Ownership Change: <br /> KAMPGROUNDS OF AMERICA Owner or Corp.Name: <br /> 14900 W HIGHWAY 12 <br /> LODI,CA 95242-9325 Address: <br /> (209)369-1041 <br /> (209)369-1317 City/State/Zip: <br /> Telephone: Fax: <br /> 6. ❑ CHECK TO CANCEL THE EPA ID NUMBER SHOWN ON LINE 1. ID NUMBER WILL BE CANCELED EFFECTIVE 6130109. <br /> If you checked this box in prior year(s)and did not manifest in 2008, please contact our office. (See back for more info.) <br /> 7. COMPANY NAME: Company Name Change: <br /> If no change, please leave blank. <br /> TOWER PARK RESORT <br /> 8. CONTACT INFO: Contact Info Change: If no change, please leave blank. <br /> SHERRI KEYS Name/Title: <br /> 14900 W HIGHWAY 12 <br /> LODI,CA 95242-9325 Address: <br /> (209)369-1041 <br /> (209)369-1317 City/State/Zip: <br /> TPREGION@AOL.COM <br /> Telephone: Fax: <br /> Business Email Address: <br /> 9. SIC CODE (4 digits): If printed SIC Code is incorrect or blank,please provide correct information. <br /> 9999 _ _ _ _ See instructions on back for SIC Code information. <br /> 10. 1 hereby certify under penal of per" ry tha the informa on above and on the f e forms is true and correct. <br /> Name(please pr f� I�'L��/•//G[/E�O Title: 1 rA m° r2 /'�/� J �5:5��� / <br /> Si at . 6 Date: 7 4 d <br /> DTS 93( 1 1 <br /> 70580 <br /> 010 <br />