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p <br /> Account#: ssss <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4) JIFFY LUBE#598 BUSINESS PHONE(5) 209-239-0665 <br /> SITE ADDRESS (6) 1130 N❑ MAIN <br /> Street No. Direction Street Name SS eet T AA t/BI <br /> CITY (7) MANTECA STATE(8) CA ZIP(9) 95336 <br /> DUN& (10) 602035032 SIC CODE(4 DIGIT#)(11) <br /> BRADSTREET 7549 <br /> OPERATOR (12)BROADBASE INC OPERATOR PHONE(13) 209-339-0791 <br /> NAME <br /> II.BUSINESS OWNER <br /> OWNER NAME(14) DONALD W FOWLER OWNER PHONE(15) 209-339-0791 <br /> OWNER MAILING ADDRESS(16) 730 S BECKMAN RD. #B <br /> (If different from site address) <br /> CITY(17) LODI STATE(18) CA ZIP(19) 95240 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) PHILL DOSIER/GLEN GANOTIS CONTACT PHONE(21) 209-339-0791 <br /> MAILING ADDRESS (22) <br /> (If different from business 730S BECKMAN RD #B <br /> mailing address) <br /> Street No. Direction Street Name Street T e A t/Bld Suite <br /> CITY(23) FTHROP STATE(24) E <br /> ZIP(25) 95330 <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) PHILL DOSIER NAME(3 1) GLEN GANOTIS <br /> TITLE(27) TITLE(32) <br /> OPERATION MANAGER ENVIRONMENTAL & SAFETY <br /> BUSINESS PHONE(28) 209-339-0791 BUSINESS PHONE(33) 209-339-0791 <br /> 24-HOUR PHONE(29) 209-298-2865 24-HOUR PHONE(34) 209-298-5373 <br /> PAGER#(30) 209-298-2865 PAGER#(35) 209-938-4030 <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) GLEN GANOTIS <br /> NAME OF OWNER/OPERATOR(39) DONALD W FOWLER DATE(40) <br /> DATE REC'D: 12/19/03 <br />