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IyFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:03/22/2011 <br /> Last Website Update: 1/25/2011 Page_ of <br /> 1. IDENTIFICATION <br /> FACILITY IDX 13089 1 1 BEGINNING DATE N/A 100 ENDING DATE N/A 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 <br /> PIZZA FACTORY 209-607-7787 102, <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX <br /> 14088 E HWY 88 Not Collected <br /> BUSINESS SITE CITY 104 ZIP CODE105 COUNTY 108 <br /> LOCKEFORD CA 95209 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a <br /> 131602989 5812 Not Collected <br /> BUSINESS MAILING ADDRESS 108a <br /> P.O.BOX 1700 <br /> BUSINESS MAILING CITY 1081 STATE 108c ZIP CODE I 08 <br /> IONE CA 95640 <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> DANIEL NEHER 209-607-7787 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) I I I I OWNER PHONE(15) 112 <br /> DANIEL NEHER 209.607-7787 <br /> OWNER MAILING ADDRESS 113 <br /> 14088 E HWY 88 <br /> OWNER MAILING CITY 114 STATE 115 ZIP CODE 116 <br /> LOCKEFORD CA 95237 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 CONTACT PHONE 118 <br /> DANIEL NEHER 209-607-7787 <br /> CONTACT MAILING ADDRESS 119 1 CONTACT EMAIL 119a <br /> PO BOX 1700 Iockefordpi=afactoryQhotmail.com <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> IONE CA 95640 <br /> IV. EMERGENCY CONTACTS <br /> NAME 123 NAME 128 <br /> TIM FLORES DANIEL NEHER <br /> TITLE MANAGER OWNER 124 TITLE 129 <br /> BUSINESS PHONE 209-727-3707 125 BUSINESS PHONE 209-607-7787 130 <br /> 24-HOUR PHONE 209-603-5698 126 24-HOUR PHONE 209-607.7787 131 <br /> PAGER/CELL X 209-603-5698CELL 127 PAGERICELL X NA 132 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133 <br /> COMPLETE PAGE 2 OF BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Certification: Based on my inquiry of those individuals responsible for obtaining the information,I certify under penalty of law by signing below or certifying by the <br /> established processes on the Administening Agency's HMMP Compliance Website that I have personally examined and am familiar with the infortmaiton submitted and <br /> believe the information is one,accurate,and complete. <br /> SIGNATURE OF OWNhWOPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 1 NAME OF DOCUMENT PREPARER 135 <br /> NAME OF SIGNER(print) 136 FITLE OF SIGNER 137 <br /> UPCF Rev. 12/200 <br />