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I. IDENTIFICATION <br />BUSINESS NAME (4) MCCOY TRUCK TIRE SERVICE BUSINESS PHONE (5) <br />CTR INC �� <br />SITE ADDRESS (6> 3726 IS I <br />MW 99 I r <br />CITY (7) ISTOCKTON I STATE (8)ICA I ZIP (9) <br />DUN & (10)071858070 SIC CODE (4 DIGIT #) (11) <br />BRADSTREET <br />OPERATOR (12)JOE KREZEWINSKI OPERATOR PHONE (13) 20' <br />NAME <br />II. BUSINESS OWNER <br />OWNER NAME (14) JAMES BARNICK OWNER PHONE (15) 209-466-4551 <br />OWNER MAILING ADDRESS (16) 1407 LONE PLAN AVE <br />(If different from site address) <br />CITY (17) MODESTO I <br />STATE (18) FCA -1 ZIP (19) 95351 <br />CONTACT NAME (20) MARC FINNEGAN <br />MAILING ADDRESS (22) 1407 F <br />LONEPALM <br />AVE N/A <br />(If different from business <br />mailing address) Street No. Direction <br />CONTACT PHONE (2 1) 209-521-6221 <br />CITY (23) 1_ STATE (24) 1, � I ZIP (25) <br />Primary IV. EMERGENCY CONTACTS Secondary <br />NAME (26) MARC FINNEGAN I I <br />NAME (3 1) JOE KRZEWINSKI <br />TITLE (27) (VICE PRESIDENT I I TITLE (32) (RETREAD SHOP MANAGER <br />BUSINESS PHONE (28)1 ... e.. cggz I I BUSINESS PHONE (33) <br />24-HOUR PHONE (29) 1,)no_c,)i _���i 11 24-HOUR PHONE (34) <br />PAGER # (30) IN/A I I PAGER # (35) IN/A <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) MARC FINNEGAN <br />NAME OF OWNER/OPERATOR (39) IBARNICK JAMES I DATE (40) <br />DATE REC'D: 9/22/04 <br />