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UNIFIED PROGRAM CONSOLIDATED FO <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:05/07/2009 <br /> Last Website Update: 12/18/2008 Page_ of <br /> I. IDENTIFICATION <br /> FACILITY ID# 2876 1 BEGINNING DATE N/A 100 ENDING DATE 101 <br /> N/A <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 <br /> TED'S WELDING&REPAIR 209-368-9864 <br /> BUSINESS SITE ADDRESS 103 I BUSINESS FAX lnl <br /> 8932 E HWY 12 Not Collected <br /> BUSINESS SITE CITY104 ZIP CODE 105 COUNTY 108 <br /> VICTOR CA 95253 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a <br /> 55-569.2672 2876 Not Collected <br /> BUSINESS MAILING ADDRESS lOBa <br /> P.O.BOX 726 <br /> BUSINESS MAILING CITY 1081 STATE 109c ZIP CODE 1085 <br /> VICTOR CA 95253 <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> BILL(GEORGE)BRAUN 209-365-9416 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) 1I I I OWNER PHONE(15) 112 <br /> BILL(GEORGE)BRAUN 209-365-9416 <br /> OWNER MAILING ADDRESS 113 <br /> P.O.BOX 611 <br /> OWNER MAILING CITY 114 STATE 115 ZIP CODE 116 <br /> VICTOR CA 95253 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 1 CONTACT PHONE 118 <br /> BILL BRAUN 209-368-9864 OR 209-365 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL ]19a <br /> 8832 E HWY 12 RD tedsweldQconacast.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 /> 1 <br /> TITLE OWNER N/A 124 TITLE 129 <br /> BUSINESS PHONE 209-368-9864 125 BUSINESS PHONE N/A 130 <br /> 24-HOUR PHONE 209.365-9416 HM 126 24-HOUR PHONE N/A 131 <br /> PAGER# 209-603.8979 CELL 127 PAGER# 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,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 1 have personally examined and am familiar with the infonnaiton submitted and <br /> believe the information is true,accurate,and com lege. <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 NAME OF DOCUMENT PREPARER 135 <br /> NAME OF SIGNER(print) 136 TITLE OF SIGNER 137 <br /> UPCF(Rev.12/2007) <br />