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to of California—California Environmental Protection Agency Generator Information Services Section <br /> Department of Toxic Substances Control 454-4012 (Calif.Callers Only Toll Free) <br /> P.O. Bax 1288 • or 1-916-255-4439(Outside Calif.) <br /> Sacramento, CA 95812-1288 www.dtsc.ca.gov <br /> 2008 VERIFICATION QUESTIONNAIRE <br /> (See back of this form for instructions,guidance and statutory requirements.) <br /> ALL FORMS MUST BE RETURNED IN THE ENCLOSED ENVELOPE WITHIN 30 DAYS FROM THE DATE OF RECEIPT. All business information <br /> must be verified per Health&Safety Code section 25205.16(c). Failure to return all forms will lead to the suspension of your EPA Identification Number. <br /> Please type or print clearly and use only standard abbreviations. <br /> Mailing address change. <br /> TOWER PARK RESORT Street 1: <br /> 14900 W HIGHWAY 12 Street 2: <br /> LODI,CA 95242-9325 City/State/Zip:. <br /> DO NOT WRITE IN THIS AREA. If information in this box is incorrect, call (877) 454-4012 <br /> 1. EPA ID Number: CAL000319999 <br /> 2. Location address: 14900 W HIGHWAY 12 LODI,LODI,CA 95242-9325 <br /> If your business moved, a new EPA 1D is required. Go to www.dtsc.ca.-gov/IDManifestlindex.cfm. <br /> 3. FEDERAL EMPLOYER NUMBER (FEIN): (Required) <br /> 4. BOARD OF EQUALIZATION NUMBER(BOE): <br /> 5. COMPANY OWNER INFO: NOTE: Only update if you have a U.S. EPA (federal) EPA ID number. <br /> California EPA ID numbers are NOT transferable to another owner. <br /> KAMPGROUNDS OF AMERICA DO NOT fill in new owner information below if you have a Califomia EPA ID <br /> 14900 W HIGHWAY 12 number. Check Box 6 to cancel this EPA ID number. <br /> LODI,CA 95242.9325 Company Owner or Corp. Name: <br /> (209)369-1041 Address: <br /> (209)369-1317 <br /> City/State2ip: <br /> Telephone Fax <br /> Date of Ownership Change: <br /> 6. ❑ Check here if you wish to CANCEL the EPA ID number shown on Line 1. <br /> 7. COMPANY NAME: If printed company name is incorrect or has changed please update. <br /> T ►vulcl� Pa2a< MAcz; >Jd <br /> 8. CONTACT INFO: If printed contact is irtcorrect or has changed,please update. <br /> SHERRI KEYS Namelritle: <br /> 14900 W HIGHWAY 12 <br /> LODI,CA 95242-9325 Address: <br /> (209)369-1041 City/State/Zip: <br /> (209)369-1317 Telephone Fax <br /> TPREGION@AOL.COM <br /> Business email address: <br /> 9. SIC CODE(4 digits): If printed SIC Code is incorrect or blank, please provide correct information. <br /> 9999 <br /> 10. 1 here y cet' Undpe, Ity f perjury that the information abov andlon the fee forms is true and correct. <br /> Signa r Date ��]j1/ /g d. ! <br /> Nam pl e print) y r� 1,61138 Title:)UM;cwt S 1� o A/1/ <br /> DTSC 1193[front](9/08) ® Printed on Recycled Paper <br /> 1 <br /> amc <br /> U0 <br />