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BUSINESS OWNER/OPERATOR IDENTIFICATION FORM <br />1 11 Account #: 363 <br />BUSINESS NAME (4) <br />SITE ADDRESS (6)13105 <br />CITY (7) <br />DUN & (10) <br />BRADSTREET <br />OPERATOR (12) <br />NAME <br />I. IDENTIFICATION <br />TANK LINES INC I BUSINESS PHONE (5) <br />IF -11 EL DORADO FT <br />n Street Name —St <br />KTON STATE (8) CA ZIP (9) 195206 <br />-1606 SIC CODE (4 DIGIT #) (11) 14213 <br />AEL ELLIS OPERATOR PHONE (13)209-466-3554 <br />U. BUSINESS OWNER <br />OWNER NAME (14) CALIFORNIA TANK LINES OWNER PHONE (15) 1209-466-3554 <br />OWNER MAILING ADDRESS (16) P.O. BOX 6245 <br />(If different from site address) <br />M. ENVIRONMENTAL CONTACT <br />CONTACT NAME (20) JACK BISHOP CONTACT PHONE (2 1) 209-46635 <br />MAILING ADDRESS (22) <br />(If different from site address) ❑ P.O. BOX 6245 <br />Street No. Direction Street Name Street T <br />CITY (23) STATE (24) F__ I ZIP (25) <br />IV. <br />NAME (26) IMICHAEL ELLIS <br />I= (27) <br />BUSINESS PHONE (28) <br />24-HOUR PHONE (29) <br />PAGER # (30) <br />NAME (3 1) IJACK BISHOP <br />TITLE (32) IMAINTENANCE SUPERVISOR <br />BUSINESS PHONE (33) <br />24-HOUR PHONE (34) <br />PAGER # (35) <br />EXTREMELY HAZARDOUS SUBSTANCES (ERS) <br />ON-SITE EHS (36) YES 1 If yes, and above Threshold Planning Quantities, attach a sheet of paper with a general <br />description of the process and principle equipment involved with the EHS. <br />ADDITIONAL LOCALLY COLLECTED INFORMATION (37) Provide information requested on the 2nd page of this form <br />NAME OF DOCUMENT PREPARER (38) <br />JACK BISHOP / CINDY KOCHEVAR <br />NAME OF OWNER/OPERATOR (39) MICHAEL ELLIS DATE (40) <br />