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• UNIFIED PROGRAM CONSOLIDATED FORNr <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:05/07/2009 <br /> Last Website Update: 2/28/2009 Page_ of <br /> L IDENTIFICATION <br /> FACILITY ID# 12410 1 BEGINNING DATE NSA 100 ENDING DATE N/A 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 <br /> CAR QUEST 209-943-1000 <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX IQ <br /> 1645 E MINER AVE Not Collected <br /> BUSINESS SITE CITY 104 ZIP CODE 105 COUNTY 108 <br /> STOCKTON CA 95205 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a <br /> NA 5012 Not Collected <br /> BUSINESS MAILING ADDRESS 108 <br /> BUSINESS MAILING CITY 108t STATE 108c ZIP CODE 108d <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> JERRY JOHNSON 209.943-1000 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) 111 1 OWNER PHONE(15) 112 <br /> GOLDEN STATE SUPPLY 209-943.1000 <br /> OWNER MAILING ADDRESS 113 <br /> 34928 MC MURTREY WAY <br /> OWNER MAILING CITY 114 STATE 11-IZIPCODE 116 <br /> BAKERSFIELD CA 93305 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 1 CONTACT PHONE 118 <br /> JERRY JOHNSON 209.943-1000 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119a <br /> 0 NA AVE NA cheri.gillies@gpi.com <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> NA NA NA <br /> IV. EMERGENCY CONTACTS <br /> NAME JERRYJOHNSON 123 NAME BARTSCOTT 128 <br /> 1 <br /> TITLE 124 TITLE 129 <br /> MANAGER REGIONAL MANAGER <br /> BUSINESS PHONE 209.943-1000 125 BUSINESS PHONE 916-446-4666 130 <br /> 24-HOUR PHONE 209-670-6576 126 24-HOUR PHONE 916-873-2181 131 <br /> PAGER# NA 127 PAGER# 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 Administerting Agency's HMMP Compliance Website that I have personally examined and am familiar with the informaiton submitted and <br /> believe the information is me,accurate,and complete. <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 1 NAME OF DOCUMENT PREPARER 135 <br /> NAME OF SIGNER(print) 136 rITLE OF SIGNER 137 <br /> UPCF(Rev.12/2007) <br />