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5 (a D <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Pae of <br /> L IDENTIFICATION <br /> FACILITY ID# ) BEGINNING DATE 10a ENDING DATE 101. <br /> (Agency use Only) <br /> BUSINESS NAME(s.me as FACIIrIY NAME DBA-oo4B..M) 3. BUSINESS PHONE 102 <br /> LL4� v Gal <br /> BUSINESS SITE ADDRESS 103. <br /> fool W. C w <br /> CrfY IPt• ZIP CODE tos. <br /> CA <br /> DUN&BRADSTREET 10a SIC CODE(4 digit#) 107. <br /> m <br /> COUNTY <br /> G <br /> BUSINESS OPERA OR NAME 109. BUSINESS OPERATOR PHONE 110. <br /> •/Aa 1 <br /> II. BUSINESS OWNER <br /> OWNER NAME 111. OWNER PHONE 112 <br /> SAN pow - 2,1424 <br /> OWNER MAILING ADDRESS 3D. <br /> 001 W <br /> CITY a STATE s. 1 ZIP CODE 116. <br /> S <br /> M. ENVIRONMENTALCONTACT <br /> CONTACT NAME 1)7. CONTACT PHONE Ila <br /> D -w 14. 34t <br /> CONTACT MAILING ADDRESS 119. <br /> 0 la ! <br /> CITY 120 STATE 121. ZIP CODE in <br /> S ei G <br /> _PRIMARY- W. EMERGENCY CONTACTS -SECONDARY- <br /> NAME 121 NAME 128. <br /> 7)A A t•! 04 "l� v <br /> TITLE U,4- TITLE 129' <br /> BUSINESS PHONE III. BUSINESS PHONE 130. <br /> 4G5 3421 CZca)44.5- <br /> 24-HOUR PHONE' 17A. 24-HOUR PHONE' 131. <br /> incl- 45 - 7CJ Z - 1570 <br /> PAGER# In. PAGER# 132 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> Property Owner: Phone No.: <br /> Billing Address: <br /> Certification: Based on my inquiry of those individuals responsible for obtaining the infommtion,I certify under penalty of law that I have personally examined and <br /> am familiar with the information submitted and believe the information is true,accurate,and complete. <br /> SIG URE OF OWNER/OPERATOR QR DESIGNAT RFSENTATIVE DATE 13a NAME OF DOCUMENT PREPARER <br /> 616A,"An, ls//I/� 7 <br /> NAMERF SIGNER(pnt) U4. TITLE SIGNER U1 <br /> K�^1Az-D • A•J �e .¢eller <br /> 'See Instructions on next page. <br /> UPCF hwf2730(1/99)-1/2 http://"w.unidom.org Rev.04/17/00 <br />