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AWL FIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION Modification Date: 03/22/2011 Last Website Update: � Page of 1. IDENTIFICATION FACILITY ID# 14489 1 BEGINNING DATE N/A 100 ENDING DATE N/A 101 BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 SUBWAY BUSINESS PHONE 000-000-0000 102 109 BUSINESS SITE ADDRESS 25440 SCHULTE RD 103 BUSINESS FAX Not Collected BUSINESS SITE CITY TRACY 104 CA ZIP CODE 105 95377 COUNTY SAN JOAQUIN 108 DUN & BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS Not Collected 107a BUSINESS MAILING ADDRESS 108a BUSINESS MAILING CITY lost STATE 108c ZIP CODE I08d BUSINESS OPERATOR NAME AMAYIT KAUR 109 BUSINESS OPERATOR PHONE 000-000-0000 110 II. BUSINESS OWNER OWNER NAME (14) HARDEEP SINGH 111 OWNER PHONE (15) 000-000-0000 112 OWNER MAILING ADDRESS 113 OWNER MAILING CITY 114 STATE IIS ZIP CODE 116 III. ENVIRONMENTAL CONTACT CONTACT NAME AMAYIT KAUR 117 CONTACT PHONE 000-000-0000 118 CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119a CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 IV. EMERGENCY CONTACTS NAME 123 NAME 128 TITLE 124 TITLE 129 BUSINESS PHONE 125 BUSINESS PHONE 130 24-HOUR PHONE 126 24-HOUR PHONE 131 PAGER/CELL # 127 PAGER/CELL # 132 ADDITIONAL LOCALLY COLLECTED INFORMATION: COMPLETE PAGE 2 OF BUSINESS O WNER/OPERATOR IDENTIFICATION 133 Cenifica nm: 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 established processes on the Administering Agency's HMMP Compliance Website that 1 have personally examined and am familiar with the informaiton submitted and believe the information is true, accurate, and complete. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 1 NAME OF DOCUMENT PREPARER 135 NAME OF SIGNER (print) 136 TITLE OF SIGNER 137 UPCF (Rev. 12/2007)