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IFIED PROGRAM CONSOLIDATED FORMW <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Page 1 of I <br /> I.IDENTIFICATION <br /> FACILITY ID# I FA0012475 BEGINNING DATE I W ENDING DATE 101 <br /> BUSINESS NAME(Sa as FACILITY NAME v DBA-Doing Busims As) 3 BUSINESS PHONE 102 <br /> CEN CAL PLASTERING INC 209 858-9766 <br /> BUSINESS SITE ADDRESS 103 <br /> 15300 S MCKINLEY AVE <br /> CITY laa ZIP ODE los <br /> LATHROP CA 95330 <br /> DUN&BRADSTREET 10G SIC CODE(4 digit 9) 107 <br /> 1742 <br /> COUNTY <br /> IN <br /> SAN JOA UIN COUNTY <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> JEFF GANN <br /> II.BUSINESS OWNER <br /> OWNER NAME 111 OWNER PHONE <br /> uz <br /> GANN JEFF <br /> OWNER MAILING ADDRESS 113 <br /> 9373 S PRIEST RD <br /> CITY 114 I STATE 115 ZIP CODE 1I6 <br /> FRENCH CAMP CA 95231 <br /> III. ENVIRONMENTAL CONTACT <br /> 117 CONTACTPHONE 118 <br /> SANDRA GRANT BROWN (209)858-9766 <br /> CONTACT MAILING ADDRESS 119 <br /> CITY 120 STATE I31 ZIP CODE 122 <br /> -PRIMARY- IV.EMERGENCY CONTACTS -SECONDARY- <br /> NAME 123 NAME 129 <br /> JEFF GANN SANDRA GRANT BROWN <br /> TITLE 124 TITLE 129 <br /> PRESIDENT SAFETY COORDINATER <br /> BUSINESS PHONE 125 BUSINESS PHONE 130 <br /> 209 858-9766 209 858-9766 <br /> 24-HOUR PHONE 126 24-HOUR PHONE 131 <br /> 209 993-2280 209 4564170 <br /> PAGER# 121 PAGER# 132 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133 <br /> Certification: Based on my inquiry of those individuals responsible for obtaining the information,I certify under penalty of law that I have personally examined and am familiar with <br /> the information submitted and believe the information is true,accurate,and complete. <br /> SIGNATURE OF OWNEIVOPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 1 NAME01D000MENTPREPARAR 135 <br /> NAME OF SIGNER(privt) � 136 =E OF SIGNER 137 <br /> /`a/ <br /> UPCF( 1/99 revised) ` l" " I ' <br />