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ED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:01/12/2010 <br /> Last Website Update: 1/07/2008 Page_ of <br /> I. IDENTIFICATION <br /> FACILITY ID# 968 1 1 BEGINNING DATE NSA 100 ENDING DATE NSA lot <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 <br /> MANTECA EQUIPMENT RENTAL 209-239-3507 <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX <br /> 616 S MAIN ST Not Collected <br /> BUSINESS SITE CITY104 ZIP CODE 105 COUNTY 108 <br /> MANTECA CA 95337 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a <br /> 19-070-1938 1223 Not Collected <br /> BUSINESS MAILING ADDRESS 108a <br /> BUSINESS MAILING CITY 1081 STATE 108c ZIP CODE I08d <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> JIM SALMON 209-239-7736 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) 111 1 OWNER PHONE(15) 112 <br /> MANTECA EQUIP RENTAL 209-239-3507 <br /> OWNER MAILING ADDRESS 113 <br /> 616 S.MAIN ST. <br /> OWNER MAILING CITY 114 STATE 115ZIPCODE 116 <br /> MANTECA CA 95337 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 CONTACT PHONE 118 <br /> JAMES SALMON 209-239.3507 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL 1192 <br /> 616 S MAIN ST califsalmonQyahoo.com <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> MANTECA CA 95337 <br /> IV. EMERGENCY CONTACTS <br /> NAME JAMES SALMON 123 NAME DONALD SALMON 128 <br /> TITLE <br /> PRES 124 TITLE BOARD MEMBER 12 <br /> BUSINESS PHONE 209-239-3507 125 BUSINESS PHONE 209-239-3507 130 <br /> 24-HOUR PHONE 209 824-4412 126 24-HOUR PHONE 209-824-4412 131 <br /> PAGERICELL# NSA 127 PAGER/CELL# 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,1 certify under penalty of law by signing below or certifying by the <br /> established processes on the Administerting Agency's HMMP Compliance Website that 1 have personally examined and am familiar with the informairon submitted and <br /> believe the information is me,accumw,andcom tete. <br /> SIGNATURE OF OWNER/OPERA I U ORDESIGNATED REPRESENTATIVE DATE 134 1 NAME OF DOCUMENT PREPARER 135 <br /> NAME OF SIGNER(print) 136 TITLE OF SIGNER IT <br /> UPCF Rev.12/2007 <br />