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ESS OWN '� Account#: 10124 <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4) AUTO-CHLOR SYSTEM 71 BUSINESS PHONE(5) 209-823-8495 <br /> SITE ADDRESS (6) I SS 1122 —IF—EMER <br /> AVE #E <br /> Street No. Direction Street Name Street T e A dBld Suitc <br /> CITY (7) MANTECA STATE(8) CA ZIP(9) 95336 <br /> DUN& (10)N/A SIC CODE(4 DIGIT#)(11) N/A <br /> BRADSTREET <br /> OPERATOR (12) TREVOR AMESTOY OPERATOR PHONE(13) 209-823-8495 <br /> NAME <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) JERRY L IVY I <br /> OWNER PHONE(15) 650-967-3085 <br /> OWNER MAILING ADDRESS (16) 450 FERGUSON AVE <br /> (If different from site address) <br /> CITY(17) MTN VIEW STATE(18) CA ZIP(19) 94043 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) TREVOR AMESTOY CONTACT PHONE(21) 209-823-8495 <br /> MAILING ADDRESS(22) ❑ <br /> (If different from business <br /> mailing address) <br /> Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY(23) STATE(24) D ZIP(25)r I <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) TREVOR AMESTOY NAME(3 1) TROY HARDCASTLE <br /> TITLE(27) BRANCH MANAGER TITLE(32) INSTALLER <br /> BUSINESS PHONE(28) 209-823-8495 BUSINESS PHONE(33) 209-823-8495 <br /> 24-HOUR PHONE(29) 209-456-1310 24-HOUR PHONE(34) 209-652-6623 <br /> PAGER#(30) N/A PAGER#(35) N/A <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) NQ If yes,and above Threshold Planning Quantities,attach a sheet of paper with a general <br /> description of the process and principle equipment involving the EHS. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION(37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER(38) TREVOR AMESTOY <br /> NAME OF OWNER/OPERATOR(39) JERRY IVY DATE(40) <br /> DATE REC'D: 12/28/05 <br />