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FIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION Modification Date:03/22/2011 Last Website Update: 01/19/2010 Page_ of_ I. IDENTIFICATION FACILITY ID# 14236 I 1 BEGINNING DATE N/A 100 ENDING DATE 101 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 N/A DANS TIRE AND AUTO REPAIR LLC 209-334-2969 BUSINESS SITE ADDRESS 103 BUSINESS FAX 1533 S STOCKTON ST Not Collected BUSINESS SITE CITY 104 ZIP CODE 105 COUNTY 108 LODI CA 95240 SAN JOAQUIN DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a 926524034 3533 Not Collected BUSINESS MAILING ADDRESS 108a BUSINESS MAILING CITY 108 STATE I08cZIP CODE 108d BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE I]0 CLIFF HALL 209-334-2969 II. BUSINESS OWNER OWNER NAME(14) 111 1 OWNER PHONE(15) 112 CLIFF HALL 209-3342969 OWNER MAILING ADDRESS 113 1533 S STOCKTON ST OWNER MAILING CITY 114 STATE 115 ZIP CODE 116 LODI CA 95240 III. ENVIRONMENTAL CONTACT CONTACT NAME 117 CONTACT PHONE 118 CLIFF HALL 209-3342969 CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119a 1533 S STOCKTON ST caseyCaPhaynesinvestments.com CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 LODI CA 95240 IV. EMERGENCY CONTACTS NAME 123 NAME 128 CASEY HAYNES CLIFF HALL TITLE 124 TITLE OWNER OWNER 129 BUSINESS PHONE 209.712-2674 125 BUSINESS PHONE 130 209-334.2969 24-HOUR PHONE 209-712-2674 126 24-HOUR PHONE 131 209-334-2969 PAGER/CELL# 209-712-2674 127 PAGER/CELL# 132 209-334-2969 ADDITIONAL LOCALLY COLLECTED INFORMATION: 133 COMPLETE PAGE 2 OF BUSINESS OWNER/OPERATOR IDENTIFICATION 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 established processes on the Administerting Agency's HMMP Compliance Website that 1 have personally examined and am familiar with the irr oonaium submitted and believe the information is true,accurate,and com tete. 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)