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BUSINESS OWNER/OPERi*R IDENTIFICATION FORM • SIDE 2 <br /> ` i=l VC BUSINESS MAILING AND BILLING INFORMATION <br /> MAII P►D>?B41) Q ,,q 5 <br /> (If different from Si dress) �Y 7 <br /> )� gf2ime sensitive and Street No. Direction Street Name Street Type <br /> official correspondence will s> M �� <br /> be sent to this address <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 PorPoration <br /> ingle Owner ❑Partnership UNSTAFFED SITE NETWORK(44) ❑yES QNO <br /> ORGANIZATION (43) C3 Public Agency <br /> ASSESSOR PARCEL NO. (45) <br /> bo .��Ci <br /> PROPERTY OWNER (46) PHONE NO. (47) <br /> NAME �t�l�'TR,1�'S3tC�t( �� `Zeq.3Z;'1.2..5� -. <br /> (If different from Business Owner) <br /> PROPERTY OWNER (48) <br /> ADDRESS <br /> Street Address <br /> Lo9�' cow c�S'L�2 <br /> CITY STATE ZIP <br /> FIRE DISTRICT (49) <br /> ►.,sooh�Q:�bt <br /> NEAREST CROSS (50) <br /> STREET <br /> FACILITY (51) ❑YES IF YES' <br /> LOCKBOX WHERE IS IT LOCATED?(52) <br /> NATURE OF BUSINESS (53) �2�GK 5/ DP 6106 SVI 1 <br /> WASTE GENERATOR (54) ❑ YES, <br /> WYES �NO WHAT IS YOUR EPA NO.?(55) <br /> TRADE SECRET (56) SPILL PREVENTION (57) <br /> INFORMATION AND COUNTERMEASURES A/? <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 />