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BUSINESS OWNER/U NTI1 [CATION FORM. Account#: 936 <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4)IJAIJ,CK IN THE BOX#3408 BUSINESS PHONE(5) 209-943-2157 <br /> SITE ADDRESS (6) 4989 ::::IF—IF <br /> ❑ HWY 99 =� <br /> Street No. Direction Street Name Street T e A tBld Suite <br /> CITY (7) STOCKTON STATE(8)F— <br /> CA ZIP(9) 95215 <br /> DUN& (10)04-211-7200 SIC CODE(4 DIGIT#)(11) 5812 <br /> BRADSTREET <br /> OPERATOR (12)JACK IN THE BOX INC OPERATOR PHONE(13) 209-943-2157 <br /> NAME <br /> 1I. BUSINESS OWNER <br /> OWNER NAME(14) JACK IN THE BOX INC OWNER PHONE(15) 858-571-2689 <br /> OWNER MAILING ADDRESS(16) 9330 BALBOA AVE <br /> (If different from site address) <br /> CITY(17) SAN DIEGO STATE(18) CA ZIP(19) 92123-1516 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) pAUL DENEKA CONTACT PHONE(21) 858-571-2689 <br /> MAILING ADDRESS (22) <br /> (If different from business 9330 BALBOA AVE <br /> mailing address) 1 171 11 <br /> Street No. Direction Street Name Street Type A t/Bld Suite <br /> CITY(23) F <br /> DIEGO STATE(24) CA ZIP(25) 92123-1516 <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) ISOKNY CARAS NAME(3 1) �CARLO VERDUGO <br /> TITLE(27) MGR TITLE(32) AREA MGR <br /> BUSINESS PHONE(28) 209-943-2157 BUSINESS PHONE(33) 209-476-4603 <br /> 24-HOUR PHONE(29) 209-477-8395 24-HOUR PHONE(34) 209-401-2009 <br /> PAGER#(30) N/A PAGER#(35) N/A <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) NQ If yes,and above Threshold Planning Quantities,attach a sheet of paper with a general <br /> description of the process and principle equipment involving the EHS. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION(37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER(38) PAUL DENEKA <br /> NAME OF OWNER/OPERATOR(39) JACK IN THE BOX INC. DATE(40) <br /> DATE REC'D: 1/18/05 <br />