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BUSINESS OWNER/OPER --)R IDENTIFICATION FORM SIDE 2 <br /> E^ `�y,,�n BUSINESS MAILING AND BILLING INFORMATION <br /> MAILINGv DLI11tlb$S("d l) <br /> (ff di�f�i tr ess) ✓/ � <br /> and Street No. Direction Street Name Street O e sent to tgiwiES y} <br /> be sent to this address <7C <br /> CITY STATE ZIP <br /> BILLING ADDRESS(42) <br /> If different from above, <br /> include"Care of"information <br /> ADDITIONAL BUSINESS INFORMATION <br /> TYPE OF ingle Owner ❑Partnership UNSTAFFED SITE NETWORK(44) <br /> ORGANIZATION (43) Corporation ❑Public Agency 0 S NO <br /> ASSESSOR PARCEL NO. (45) <br /> rC- ✓Y. <br /> PROPERTY OWNER (46) PHONE NO. (47) <br /> NAME �' — ©C' 12 <br /> (If different from Business Owner) y r <br /> PROPERTY OWNER (48) <br /> ADDRESS <br /> All <br /> S ze <br /> Street Address <br /> i <br /> CITY STATE ZIP <br /> FIRE DISTRICT (49) <br /> NEAREST CROSS (50) <br /> STREET <br /> FACILITY (51) YES O IF YES, <br /> LOCK BOX �"` WHERE IS IT LOCATED?(52) <br /> NATURE OF BUSINESS (53) <br /> WASTE GENERATOR (54) IF YES, <br /> ®YES ❑NO WHAT IS YOUR EPA NO.?(55) OGL�2��S <br /> TRADE SECRET (56) SPILL PREVENTION (57) <br /> AND <br /> INFORMATION �f AND COUNTERMEASURES <br /> PLAN FOR THIS FACILITY <br /> TRAINING PROGRAM INFORMATION <br /> Does your business have an employee training program that includes initial training and annual refreshers? (58) ❑YES ®NO <br /> Does your business maintain written training records that show the training subject,date(s)of training, (59) ❑ <br /> names and signatures of employees trained,and names of instructor(s)? YES NO <br /> 12/03 <br />