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...... . . ... ...... <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACYLITV INFORMATION <br /> BUSINESS OWNERIOPERATOR IDENTIFICATION, PAGE 2 <br /> LOCALLY COLLECTED INFORMATION <br /> 138 rTTN(;TAFFFJ)qTTF.N�TWnTZK 139 <br /> TYPE OF ❑Single OWDer El Corporation El Partnership <br /> nD P-A NIT 7 A�MXT NO <br /> A,PQ.F.qvnR PARC.FT.N1MRFR 140 NEAREST CROSS STREET 1411 <br /> RE <br /> 12319102 MISSION <br /> PROPERTY OWNER NAME(If different from Business Owner) 142PHONE NO. 143 <br /> FASSEL ELDER 2096620952 <br /> 142P <br /> HONE <br /> OWNER STREET ADDRESS 144 1PROPERTY OWNER CITY 1411 STATE 141 ZIP CODE 147 <br /> 4880 PEACH AVENUE MANTECA CA 95337 <br /> FIRE DISTRICT NAME 148 FIRE DEPT NO. 14 FACILITY LOCK BOX 151 IF YES,WHERE IS IT LOCATED? 151 <br /> COUNTRY 6 NO N/A <br /> 152 <br /> T-JATITRF.OF RTT9TNF.Sq <br /> MINI MART&GAS - <br /> WASTE GENERATOR 153 IF YES.ENTER EPA NUMBER 154 <br /> NO N/A <br /> TRADF I;FCRF.T TWFnTzMATTON 155 SPILL PREVENTION AND COT TNTRRMEASLTRES PLAN PREPARED FOR FACILITY? 156 <br /> NO NO <br /> TRAINING PROGRAM INFORMATION 157 <br /> NO <br /> I" IF YES.ENTER EPA NUMBER <br /> N/A <br /> 1575 SPILL PREVENTION A NO('01 TNTFTZMEASURE� <br /> No <br /> Does your business maintain written training records that show the training subject,date(s)of training, NO <br /> :--A --A <br /> nT1JJTN1J(' A lnnRF'qq If diffem,Tt from rVIA""' '"vp h"T" <br /> 158 <br /> BUSINESS BILLING ADDRESS <br /> INE <br /> N/A N/A NGCITY ,,I STATE 1111 ZIP CODE 161 <br /> BUSINESS BILLING=CITY N/A N/A <br /> N/A <br /> This area intentionally left blank <br />