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BUSINESS OWNER/OPERATOR IDENTIFICATION FORM Account N: F976 <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4)[SHELL (99) BUSINESS PHONE(5) 1209-957-539S <br /> SITE ADDRESS (6) 17700 F—] MORELAND CT <br /> Street No. Direction Street Name Street T Art/Bld Suite <br /> CITY (7) STOCKTON STATE(8) CA "LIP(9)195212 <br /> DUN& (10)00-429-4737 SIC CODE(4 DIGIT#)(11) 5541 <br /> BRADSTREET <br /> OPERATOR (12)BALAJI&CHHAYA OPERA"fOR PHONE(13) 209-957-53913 <br /> NAME ANGLE <br /> II.BUSINESS OWNER <br /> OWNER NAME(14) FAL;�il& CHHAYA ANGLE OWNER PHONE(15)1209-957-5398 <br /> OWNER MAILING ADDRESS(16) 7700 MORELAND CT <br /> (If different from site address) <br /> CITY(17) FTOCKTON I l <br /> STATE(18) E <br /> ZIP(19) 95212 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) ti o r tri �R D r m n q *z CONTAC}T.PHONE(21) <br /> u�ee dr f a�v o '1S d T�- •V /� 209- 7DV J T.� ,.��/ �.. <br /> MAILING ADDRESS(22) a �� <br /> (If different from site address) NT ttk�- Iul�l— <br /> Street No. Direction Street Name Street T e Aot/Blde/Suite <br /> CITY(23) binnFCT() F7R (��M O M STATE(24) CA ZIP(25) , <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) JESSE PARMAR � NAME(3 1) BALA.TI ANGLE <br /> TITLE(27) MANAGER TITLE(32) <br /> [DEALER <br /> BUSINESS PHONE(28)1209-957-5398 BUSINESS PHONE(33) 1510-654-3-" <br /> 24-HOUR PHONE(29) 1916-683-3281 24-HOUR PHONE(34) 510-792-3151 <br /> PAGER#(30) NSA PAGER#(35) 1510-552-4822 <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) NO 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 his form <br /> NAME OF DOCUMENT PREPARER(38) 1--44-1 DESIGN GROUP iN 13 4 L-11. �- � _ <br /> NAME OF OWNER/OPERATOR(39) BALAJI ANGLE DATE.(40) <br />