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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACTLITV YNFORMATTON <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Last Website Update: Page of <br /> I. ]IDENTIFICATION <br /> FAM1TTY TT)i 2876 1 1 RF.CTTNNTMCT DATF. N/A 100 ENDING DATE N/A 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doina Business As) 3 BUSINESS PHONE 102 <br /> TED'S WELDING&REPAIR 209-368-9864 19�i <br /> RTTqWFqq'TTF.AnnRFRR 103 BUSINESS FAX <br /> 8932 E HWY 12 Not Collected <br /> BUSINESS SITE CITY 1041 7TP Corip. 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 /> RT IRTM17.99 MATT.TN6 AT)nRF'q I ORa <br /> P.O.BOX 726 <br /> BUSINESS MAILING CITY 108t STATE I OR ZIP CODE 108d <br /> VICTOR CA 95253 <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE Ito <br /> BILL(GEORGE)BRAUN 209-603-8979 <br /> H. BUSINESS OWNER <br /> OWNER NAME(14) 111 j nWNFR PT-TOXF,(15) 112 <br /> BILL(GEORGE)BRAUN 209-603-8979 — <br /> nVJNF.R MATTINa AT)T)RF. .q 113 <br /> P.O.BOX 611 <br /> OWNFR MATTIMn CITY 114 STATE 11517TP Cnr)F 116 <br /> VICTOR CA 95253 <br /> 111. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 1171CONTACT PHONE 118 <br /> BILL BRAUN 209-368-9864 OR 209-365 <br /> CONTACT MAILING ADDRESS 110 CONTACT EMAIL I l9 <br /> 8832 E HWY 12 RD tedsweld@comeast.net <br /> CONTACT MAILING CITY 120 STATE 121 RTP ronF 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 ')4-"OTTR PRONF. N/A 131 <br /> PA(IF.R/C.M.I.9 209-603-8979 CELL 1271PACIMR/CF.T.T.i 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 HNST Compliance Website that I have personally examined and am familiar with the infrimiraiton submitted and <br /> SIGNATURE OF OWNERIOPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 NAME OF DOCUMENT PREPARER 135 <br />