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% <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACTT,TTV DiRORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Last Website Update: RHE= Page of <br /> I. IDENTIFICATION <br /> FACRATY TD* 13814 1 1 R17,GINNINCT DATE N/A 100JENDING DATE N/A 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doiniz Business Asl 3 BUSINESS PHONE 102 <br /> COUNTRY CLUB FOOD&FUEL 209-662-0952 <br /> 192i <br /> RTTRTNF.vq RTTR ADnRF.q.q 103 BUSINESS FAX <br /> 1856 COUNTRY CLUB BLVD Not Collected <br /> BUSINESS SITE CITY 1041 71P CnDF. 105 COUNTY 108 <br /> STOCKTON CA 95204 SAN JOAOUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107n <br /> 038569695 5411 Not Collected <br /> FtTTqFKF..';q NAAFI.TNG ADr)RF.V.q I ORS <br /> 1856 W COUNTRY CLUB BLVD <br /> BUSINESS MAILING CITY 1081 STATE I III ZIP CODE 108d <br /> STOCKTON CA 95205 <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> PHILLIP M ELDER 209-662-0952 <br /> It. BUSINESS OWNER <br /> OWNER NAME(14) 111 1 OWNFR PRONF.(15) 112 <br /> PHILLIP M ELDER 209-662-0952 <br /> OWNFR MATTING AnT)RF.q.q 113 <br /> 4880 PEACH RD <br /> OWNFR MATT.TNCT CITY 1141 STATE IIflPrnT)F, 116 <br /> MANTECA CA 95337 <br /> 111. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 1 CONTACT PHONE 118 <br /> PHILLIP M ELDER 209-662-0952 <br /> CONTACT MAILING ADDRESS 110 CONTACT EMAIL 119P <br /> 1856 W COUNTRY CLUB BLVD BLDG admin@advgeoenv.com <br /> CONTACT MAILING CITY 120 STATE 121171P 11)1)17 122 <br /> STOCKTON CA 95205 <br /> IV. EMERGENCY CONTACTS <br /> NAME PHILLIP M.ELDER 123 NAME SEAN ELDER 128 <br /> TITLE OWNER 124 TITLE N/A 129 <br /> BUSINESS PHONE 209-662-0952 125 BUSINESS PHONE 209-470-6364 130 <br /> 24-HOUR PHONE 209-662-0952 126 94-1401 FR P"O"M 209-470-6364 131 <br /> PAC,FR/r.FLT.;1 209-662-0952 127 1 P A(-,F.R/C.F.T.T. 209-470-6364 132 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133 <br /> CONTLETE,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 M%4W Compliance Website that I have personally examined and am familiar with the informaiton,submitted and <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE I DATE 134 I NAME OF DOCUMENT PREPARFR 135 <br />