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• • DECEIVED <br /> OCT 13 zo» <br /> UNIFIED PROGRAM CONSOLIDATED FORM ! N COUNTY <br /> FACILITY INFORMATION NCYSERVICa <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> (9/13/2011- 12:33:51 PM) <br /> Page of�� <br /> I. IDENTIFICATION <br /> FACILITY ID# 13249 I 1 BEGINNING DATE N/A 100 ENDING DATE N/A 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 <br /> ARCH ARCO AM/PM 209-948.2438 <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX 102; <br /> 4855 S HWY 99 Not Collected <br /> BUSINESS SITE CITY 104 ZIP CODE 105 COUNTY 108 <br /> STOCKTON CA 95215 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a <br /> 542388.0996 N/A Not Collected <br /> BUSINESS MAILING ADDRESS IOSa <br /> BUSINESS MAILING CITY 108t STATE 108c I <br /> ZIP CODE 108d <br /> 13SINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> JIVTESH GILL 209-481-7445 <br /> H. BUSINESS OWNER <br /> OWNER NAME(14) 1]I I OWNER PHONE(15) 112 <br /> JIVTESH GILL 209.481.7445 <br /> OWNER MAILING ADDRESS 113 <br /> 4855 SOUTH HWY-99 <br /> OWNER MAILING CITY 114 STATE 115 ZIP CODE 116 <br /> STOCKTON CA 95215 <br /> IH. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 CONTACTPHONE 118 <br /> JIVTESH GILL 209.481.7445 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119a <br /> sandeepsp@yaboo.com <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> IV. EMERGENCY CONTACTS <br /> NAME 123 NAME 12 <br /> JIVTESH GILL 123 GILL <br /> TITLE OWNER OWNER 124 TITLE 129 <br /> BUSINESS PHONE 209-948-2438 125 BUSINESS PHONE 209-948-2438 130 <br /> 24-HOUR PHONE 209.481-7445 126 24-HOUR PHONE 209-298-4400 131 <br /> PAGER/CELL# 209.481-7445 127 PAGER/CELL# 209-2984400 132 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: I33 <br /> COMPLETE PAGE 2 OF BUSINESS OWNERIOPERATOR IDENTIFICATION <br /> Certification: Baze y i airy of[hast' dividuals r sible for obtaining the information,I certify under penalty of law by signing below or certifying by the <br /> established processes o [he dmi srenin gency's Compliance Website that i have personally examined end am familiar with the informri[an sub niued and <br /> believetheinforamd. stru ,a mte,a comlete <br /> SIGNATURE OF f T R OR ATED REPRESENTATIVE DATE 134 NAME OF DOCUMENT PREPARE, 135 <br /> Qq•11-2t+tl SA-9-41NSfniC�J1 <br /> NAME OF SIG _ 136 E OF SIGNER <br /> 37 <br /> �� I rt 1 LL ate' ey2' UPCF(Rev.12/2007) <br />