Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION,PAGE 2 <br /> LOCALLY COLLECTED INFORMATION <br /> (01/21/2010-04:52:50 PM) <br /> 13JUNSIAFFED SITE NETWORK lis <br /> ORGANIZATION ❑Single Owner ❑Partnership <br /> ®Corporation ❑Public Agency NO <br /> ASSESSOR PARCEL NUMBER 140 NEAREST CROSS STREET 141 <br /> 119.042.28 BELVEDERE <br /> PROPERTY OWNER NAME(If different from Business Owner) 142 PHONE NO. 143 <br /> ERIC GOODMAN 209-477-1492 <br /> PROPERTY OWNER STREET ADDRESS 144 PROPERTY OWNER CITY 145 STATE 146 ZIP CODE 147 <br /> 4576 WINDING RIVER CIR. STOCKTON CA 95219 <br /> FIRE DISTRICT NAME 1 FIRE DEPT NO. 14 FACILITY LOCK BOX 15 IF YES,WHERE IS IT LOCATED? 151 <br /> STOCKTON 528A NO N/A <br /> NATURE OF BUSINESS 152 <br /> AUTO TRANSMISSION REPAIR <br /> WASTE GENERATOR 153 1 IF YES,ENTER EPA NUMBER 154 <br /> YES CAL000000215 <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 158 <br /> BUSINESS BILLING CITY 159 STATE 161 ZIP CODE 161 <br /> This area intentionally left blank <br />