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IED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:04/05/2010 <br /> Last Website Update: 04/02/2010 Page of <br /> 1. IDENTIFICATION <br /> FACILITY ID# 2876 1 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 /> TED'S WELDING&REPAIR 209-368-9864 107, <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX <br /> 8932 E HWY 12 Not Collected <br /> BUSINESS SITE CITY 104 ZIP CODE 105 COUNTY 108 <br /> VICTOR CA 95253 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107 <br /> 55.569.2672 2876 Not Collected <br /> BUSINESS MAILING ADDRESS 108 <br /> P.O.BOX 726 <br /> BUSINESS MAILING CITY 1081 STATE 108 ZIP CODE 108d <br /> VICTOR CA 95253 <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> BILL(GEORGE)BRAUN 209-603-8979 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) 111 1 OWNER PHONE(15) 112 <br /> BILL(GEORGE)BRAUN 209-603.8979 <br /> OWNER MAILING ADDRESS 113 <br /> P.O.BOX 611 <br /> OWNER MAILING CITY 114 STATE ILIZIPCODE 116 <br /> VICTOR CA 95253 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 CONTACT PHONE 118 <br /> BILL BRAUN 209-368.9864 OR 209-365 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119 <br /> 8832 E HWY 12 RD tedsweld@comcast.net <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> VICTOR CA 95253 <br /> IV. EMERGENCY CONTACTS <br /> NAME BILL BRAUN 123 NAME NONE 128 <br /> TITLE OWNER 124 TITLE N/A 129 <br /> BUSINESS PHONE 209-368-9864 125 BUSINESS PHONE N/A 130 <br /> 24-HOUR PHONE 209-603-8979 126 24-HOUR PHONE N/A 131 <br /> PAGER/CELL# 209-603-8979 CELL 127 PAGER/CELL# N/A 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,l certify under penalty of law by signing below or certifying by the <br /> established processes on the Administerting Agency's HMMP Compliance Website that 1 have personally examined and am familiar with the inforrnaiton submitted and <br /> believe the information is true,accurate,and complete <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 1 NAME OF DOCUMENT PREPARER 135 <br /> NAME OF SIGNER(print) 136 TITLE OF SIGNER 137 <br /> UPCF Rev.12/2007 <br />