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UNT FEED PROGRAM CONSOLIDATED FOPM <br />FACILITY LNFORM.ATION <br />BUSINESS O"ir-ER/OPERATOR IDENTIFICATION <br />I. IDENTIFICATION <br />FACILITY M# I t BEGINNIN9 DATE 100 ENDING DATE <br />101 <br />i i Gb fa 3 e oa <br />I <br />BUSINESS E (Same as FACILRy NAME or DRA - Doing Swims M) BUSINESS PHONE <br />11i�^ i �✓ COi �tQ` 1 r ' oAi 3Y-1164 <br />BUSINESS SITE ADrDRESS <br />- <br />t <br />103 <br />CITY 1Ot ZIP CODE <br />Ios <br />CA ni533 <br />DUN & BRADSTREET 106 SIC CODE (4 digit <br />10% <br />COUNTY <br />Ice <br />BUSINESS OPERATOR NAME 109 <br />BUSINESS OPERATOR PHONE <br />110 <br />¢126q <br />II. BUSINESS OWNER <br />OWNER NAME 111 OWNER PHONE <br />117 <br />OWNER MAILING ADDRESS <br />„y <br />CITY jIla <br />STATE IIs <br />ZIPCODE <br />iIs <br />0-1 <br />1 4 <br />9 6 <br />i <br />M. ENYMONNENTAL CONTACT <br />CONTACT NAME- / In TACT PHONE <br />Its <br />iii .5 �v <br />CONTACT MAILING ADDRESS <br />uY <br />CITY 1.° I <br />STATE 1=1 <br />ZIP CODE <br />1" <br />-PRIYIARY- IV. EMERGENCY CONTACTS -SECONDARY- <br />NAME <br />cc9s <br />M✓ie5eV Z Z <br />(O1,17--le-2"' �v�(/'P <br />TITLE1I=n' <br />'Ar/ <br />TNIATMLEE� <br />✓,2, <br />joG%?li�5�9'IS�'✓ <br />H%1Q�.f'r�4 �✓i�,tl^PP✓' <br />BLSINE S PHONE a <br />BUSINESS PHONE <br />130 <br />_a -HOUR PHO <br /> <br /> <br /> <br /> <br />PAGER f 1V <br />PAGER # <br />137 <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: <br />133 <br />Certification: Based on my inquiry of Nose Individuals responsible for obtaining the information, 1 certify under penalty of law that [ have persomlly examined and <br />am familiar with the information submitted and believe the information is me. accurate, and complete. <br />SIGNATUR OF OWNER/O"=ESIGNATED REPRESENTATIVE <br />DAT I)+ NAM DOCUMENT PR PAR <br />Ia5 <br />[� r <br />I <br />i NAME OF SIGNER (W." Ue <br />1 K. Coo l` <br />TITLE O&SIGNER <br />❑' <br />P MaEs <br />