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FIED PROGRAM CONSOLIDATED FORM OW <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:03/22/2011 <br /> Last Website Update: 1/26/2010 Page_ of_ <br /> 1. IDENTIFICATION <br /> FACILITY ID# 12445 1 BEGINNING DATE N/A 100 ENDING DATE N/A <br /> 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 <br /> BAND G TRUCK WASH 209-599-5855 <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX <br /> 816 HWY 99 FRONTAGE RD Not Collected <br /> BUSINESS SITE CITY104 ZIP CODE 105 COUNTY 108 <br /> RIPON CA 95366 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a <br /> N/A 7549 Not Collected <br /> BUSINESS MAILING ADDRESS loss <br /> 2904 CANYON <br /> DR <br /> BUSINESS MAILING CITY 108STATE 108c ZIPCODE 108d <br /> MODESTO CA 95351 <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> KULWINDER BAL 209-599-5855 <br /> I1. BUSINESS OWNER <br /> OWNER NAME(14) 111 OWNER PHONE(15) 112 <br /> AMARJIT SINGH 209.495-0544 <br /> OWNER MAILING ADDRESS 113 <br /> 2904 CANYON DR <br /> OWNER MAILING CITY 114 STATE 115ZIPTODE 116 <br /> MODESTO CA 95351 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 CONTACT'PHONE 118 <br /> KULWINDER BAL 209-495-0544 <br /> CONTACT MAILING ADDRESS I I9 CONTACT EMAIL 119a <br /> 2904 N CANYON DR bal@dr.corn <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> MODESTO CA 95351 <br /> IV. EMERGENCY CONTACTS <br /> NAME 123 NAME 128 <br /> KULWINDER BAL KULWINDER BAL <br /> TITLE 124 TITLE <br /> CO OWNER CO OWNER 129 <br /> BUSINESS PHONE 209-599.7261 125 BUSINESS PHONE136 <br /> 209-599-7261 <br /> 24-HOUR PHONE 209-341-9870 126 24-HOUR PHONE 131 <br /> 209.341-9870 <br /> PAGER/CELL# N/A 127 PAGER/CELL# 132 <br /> N/A <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,I certify under penalty of law by signing below or certifying by the <br /> established 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 emo tete. <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 1 NAME OF DOCUMENT PREPARER 135 <br /> NAME OF SIGNER(print) 136 rITLEOFSIGNER 137 <br /> UPCF Rev. 12/2007) <br />