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RECEIVED <br /> APR 19 2011 <br /> / UNIFIED PROGRAM CONSOLIDATED FORM NJOq <br /> FACILITY INFORMATION - OFFICEOFEM �F�OjJ <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION,PAGE 2 MOY R CES <br /> LOCALLY COLLECTED INFORMATION <br /> (03/11/2009- 10:55:28 AM) <br /> TYPEOFORGANIZATION <br /> 13 UN STAFFED SITE NETWORK 139 <br /> ORGAMZATTON ❑Single Owner ❑Partnership <br /> ®Corporation ❑Public Agency MO <br /> ASSESSOR PARCEL NUMBER 140 NEAREST CROSS STREET 141 <br /> 167-021-03 CHARTER WAY <br /> PROPERTY OWNER NAME(If different from Business Owner) 142 1 PHONE NO. 143 <br /> VICTOR ESALOO 408-309-2544 <br /> PROPERTY OWNER STREET ADDRESS 144 PROPERTY OWNER CITY 145 STATE 146 ZIP CODE 147 <br /> 1419 S.EL DORADO ST STOCKTON CA 95219 <br /> FIRE DISTRICT NAME JAR] <br /> FIRE DEPT NO.149 FACILITY LOCK BOX 1501F YES,WHERE IS IT LOCATED? 151 <br /> STOCKTON 22 NO N/A <br /> NATURE OF BUSINESS 152 <br /> RESTAURANT <br /> WASTE GENERATOR 153 IFYES,ENTER EPA NUMBER <br /> NO N/A <br /> TRADE SECRET INFORMATION 155 SPILL PREVENTION AND COUNTERMEASURES PLAN PREPARED FOR FACILITY? 156 <br /> NO YES <br /> TRAINING PROGRAM INFORMATION 157 <br /> Does your business have an employee training program that includes initial training and annual refreshers? YES <br /> Does your business maintain written training records that show the training subject,date(s)of training, YES <br /> names and signatures of employees trained,and names of instructor(s)? <br /> BILLING ADDRESS If different from Mailing Address,otherwise leave blank <br /> BUSINESS BILLING ADDRESS 156 <br /> BUSINESS BILLLING CITY 159 STATE 160 ZIP CODE 161 <br /> This area intentionally left blank <br />