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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACIL]TV INF(1RMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Last Website Uadate: ® Page of <br /> I. IDENTIFICATION <br /> FACTT.TTY TDs 12495 1 RFGTNNTNG DATE NSA 100 ENDING DATE NSA 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doine Business As) 3 BUSINESS PHONE 102 <br /> BAL USC 209-932-0606 <br /> RT ICINFCC CITF ADTIRFCC 103 BUSINESS FAX <br /> 4236 S HWY 99 FRONTAGE RD Not Collected <br /> BUSINESS SITE CITY 104 71P CODE 105 COUNTY 108 <br /> STOCKTON CA 95215 SAN JOAOUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107 <br /> NONE 5112 Not Collected <br /> RT TSTNFCC MATI.INO ADDRFSS IOR <br /> 4460 S HWY 99 FRONTAGE RD <br /> BUSINESS MAILING CITY 1081 STATE I tt>s ZIP CODE 108d <br /> STOCKTON CA 95215 <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> RON BARBER 209-932-0606 <br /> II. BUSINESS OWNER <br /> OWNERNAME(14) 111 nWNFRPHOWRN5) 112 <br /> RON BARBER 209-932-0606 <br /> OWNFR MAILM(I ADDRF" 113 <br /> 10411 SMALL RD. <br /> OWNER MAII.TNn C.TTY 114 STATE 115 7TP CnDF 116 <br /> MANTECA CA 95336 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 1 CONTACT PHONE 118 <br /> RON BARBER 209-932-0606 <br /> CONTACT MAILING ADDRESS 1 1 o CONTACT EMAIL 119a <br /> 4460 S HIGHWAY 99 RD rbconst@pacbell.net <br /> CONTACT MAILING CITY 120 STATE 12l 71P CODF 122 <br /> STOCKTON CA 95215 <br /> IV. EMERGENCY CONTACTS <br /> NAME JOSEPH BLACKWELL 123 NAME RON BARBER 128 <br /> TITLE GENERAL MANAGER OF 124 TITLE PRESIDENT 129 <br /> BUSINESS PHONE 209-932-0606 125 BUSINESS PHONE 209-932-0606 130 <br /> 24-HOUR PHONE 209-993-1639 126 7d-HOT TR PH()NF 209-969-2199 131 <br /> PAGFR/C.FT.1.0 NSA 127 1 PAGER/CFI1.# 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,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 /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE I DATE 134 1 NAME OF DOCUMENT PREPARER 135 <br />