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FIED PROGRAM CONSOLIDATED FORM \f <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:03/22/2011 <br /> Last Website Update: L =� Page of <br /> I. IDENTIFICATION <br /> FACILITY ID# 12529 I 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 /> ULLOA'S TOW&AUTO REPAIR 209-943-0588 lnl <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX <br /> 620 S WILSON WAY STE C Not Collected <br /> BUSINESS SITE CITY 104 ZIPCODE 105 COUNTY 108 <br /> STOCKTON CA 95205 SAN JOAQUIN <br /> DUN.&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a <br /> Not Collected <br /> BUSINESS MAILING ADDRESS - loss <br /> BUSINESS MAILING CITY 108 STATE 108c ZIP CODE 108d <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> BRENDA NARANJO 209-943-0588 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) 111 I OWNER PHONE(15) 112 <br /> ULLOA'S TOW&AUTO REPAIR 209-943-0588 <br /> OWNER MAILING ADDRESS 113 <br /> OWNER MAILING CITY 114 STATE 115 ZIP CODE 116 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 CONTACT PHONE 118 <br /> BRENDA NARANJO 209-943-0588 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119a <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> IV. EMERGENCY CONTACTS <br /> NAME 123 NAME 128 <br /> TITLE 124 TITLE 129 <br /> BUSINESS PHONE 125 BUSINESS PHONE 130 <br /> 24-HOUR PHONE 126 24-HOUR PHONE 131 <br /> PAGER/CELL# 127 PAGER/CELL# 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,1 certify under penalty of law by signing below or certifying by the <br /> esmblished processes on the Administerting Agency's HMMP Compliance Website that 1 have personally examined and am familiar with the information submitted and <br /> believe the information is true.accurate,and complete <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 />