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-16NIFIED PROGRAM CONSOLIDATED AdM <br /> FACI1.1TV mmRMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Last Website Update: ® Page_ of <br /> I. IDENTIFICATION <br /> FACH ITV IDN 8173 1 RFn1NNTNn DATE NSA 100 ENDING DATE NSA 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doine Business As) 3 BUSINESS PHONE 102 <br /> GEORGE'S MINI MART 209-727-3064 1821 <br /> RT ISTNFSS SITF.ADDRFSS 103 BUSINESS FAX <br /> 18662 N HWY 88 Not Collected <br /> BUSINESS SITE CITY 104 7TP CnDF. 105 COUNTY 108 <br /> LOCKEFORD CA 95237 SAN JOAOUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107 <br /> 94-593-7910 4511 Not Collected <br /> RITSINFSS MATT Mn ADDRFSS 1(IR <br /> BUSINESS MAILING CITY 108t STATE 109ZIP CODE 108d <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> GEORGE GALATSATOS 209-727-5028 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) Ill 1 OWNFR PHONF n Si 112 <br /> RUPINDER PADDA 209-814-5576 <br /> OWNFR MAILING ADDRFSS 113 <br /> 18662 N HWY 88 <br /> nWNFR MATTJNG CITY 114 STATE 11571P CODF 116 <br /> LOCKEFORD CA 95237 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 1 CONTACT PHONE 118 <br /> RUPINDER PADDA 209-814-5576 <br /> CONTACT MAILING ADDRESS "o CONTACT EMAIL 110, <br /> 18662 N HWY 88 lakewoodchev@yahoo.com <br /> CONTACT MAILING CITY 120 STATE 121 1 ZIP CODF 122 <br /> LOCKEFORD CA 95237 <br /> IV. EMERGENCY CONTACTS <br /> NAME RUPINDER PADDA 123 NAME HOSHIAR SODHI 128 <br /> TITLE OWNER 124 TITLE STORE MANAGER 129 <br /> BUSINESS PHONE 209-727-3064 125 BUSINESS PHONE 209-727-3064 130 <br /> 24-HOUR PHONE 209-830-7068 126 '')d-TTOTTR PHnNF. 209-814-5499 131 <br /> PAGFR/CFTT.;s 209-814-5576 127 PAGER/CFT.T.fi NSA 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 Administerting Agency's HMMP Compliance Website that I have personally examined and am familiar with the Infornaiton submitted and <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE I DATE 134 NAME OF DOCUMENT PREPARER 135 <br />