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FAccount#: 388U <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4) NICK'S 76#2611195 BUSINESS PHONE(5) 209-983-0381 <br /> SITE ADDRESS (6) 16500 ❑ LOUISE 11 <br /> AVE <br /> Street No. Direction Street Name Street Type Apt/Bldg Suite <br /> CITY (7) LATHROP STATE(8)F— <br /> CA ZIP(9) 95330 <br /> DUN& (10) 04-8564975 SIC CODE(4 DIGIT#)(11) 5541 <br /> BRADSTREET <br /> OPERATOR (12) NICK ARBABIAN OPERATOR PHONE(13) 209-478-9583 <br /> NAME <br /> 11. BUSINESS OWNER <br /> OWNER NAME(14) NICK ARBABIAN OWNER PHONE(15) 209-478-9583 <br /> OWNER MAILING ADDRESS(16) P.O.BOX 690514 <br /> (If different from site address) <br /> CITY(17) STOCKTON STATE(18) CA ZIP(19) 95269-0514 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) NICK ARBABIAN CONTACT PHONE(21) 209-478-9583 <br /> MAILING ADDRESS (22) <br /> (If different from business 904 ❑ KATHERINE WAY <br /> mailing address) Street No. Direction Street Name Street Type A t/Bld Suite <br /> CITY(23) ECKTON - :1 STATE(24) El <br /> ZIP(25) 95209 <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) NICK ARBABIAN NAME(3 1) OTIS DANCY <br /> TITLE(27) OWNER TITLE(32) DISTRICT MANAGER <br /> BUSINESS PHONE(28) 209-983-0381 BUSINESS PHONE(33) 206-706-2345 <br /> 24-HOUR PHONE(29) 209-478-9583 24-HOUR PHONE(34) 916-215-7676 <br /> PAGER#(30) N/A PAGER#(35) N/A <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) NO 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) NICK ARBABIAN <br /> NAME OF OWNER/OPERATOR(39) NICK ARBABIAN DATE(40) 10/4/2004 <br /> DATE REC'D: 1/14/04 <br />