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Account#: 1039 <br /> I. IDENTIFICATION <br /> SI SINESS NAME (4) RIPON, CITY OF PUBLIC WORKS BUSINESS PHONE(5)WELLS (0) 209-599-2108 <br /> SITE ADDRESS (6) 922 ❑ SECOND ST <br /> Street No. Direction Street Name Street Type <br /> A t/Bld Suite <br /> CITY (7) RIPON STATE(8)F— <br /> CA ZIP(9) 95366 <br /> DUN& (10) 004952156 SIC CODE(4 DIGIT#)(11) 4941,4852 <br /> BRADSTREET <br /> OPERATOR (12) TED JOHNSTON OPERATOR PHONE(13) 209-599-2108 <br /> NAME <br /> 11. BUSINESS OWNER <br /> OWNER NAME(14) CITY OF RIPON OWNER PHONE(15) 209-599-2108 <br /> OWNER MAILING ADDRESS(16) 1210SVERA AVE <br /> (If different from site address) <br /> CITY(17) RIPON STATE(18) CA ZIP(19) 95366 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) TED JOHNSTON CONTACT PHONE(2 1) 209-599-2151 <br /> II.ING ADDRESS (22) <br /> �ing ad t from business 1210 IF <br /> VERA AVE <br /> mailing address) <br /> Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY(23) RIPON STATE(24) F <br /> ZIP(25) 95366 <br /> :1 <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) TED JOHNSTON NAME(3 1) DEAN BLACK <br /> TITLE(27) PUBLIC WORKS DIRECTOR TITLE(32) PUBLIC WORKS FOREMAN <br /> BUSINESS PHONE(28) 209-599-2151 BUSINESS PHONE(33) 209-599-2151 <br /> 24-HOUR PHONE(29) 209-599-2133 24-HOUR PHONE(34) 209-599-3267 <br /> PAGER#(30) 209-236-4237 PAGER#(35) 209-599-4235 <br /> EXTREMELY HAZARDOUS SUBSTANCES (ERS) <br /> ON-SITE EHS (36) 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 /> iME OF DOCUMENT PREPARER (38) TED JOHNSTON <br /> NAME OF OWNER/OPERATOR(39) TED JOHNSTON DATE(40) <br /> DATE REC'D: 1/16/04 <br />