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FIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:03/22/2011 <br /> Last Website Update: 09/25/2009 Pipe— of <br /> 1. IDENTIFICATION <br /> 1 BEGINNING DATE N/A 100 ENDING DATE N/A 101 <br /> FACILITY ID# 7626 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 <br /> MUFFLER MAN(LODI) 209-369-5387 <br /> 102, <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX <br /> 827 N SACRAMENTO ST Not Collected <br /> BUSINESS SITE CITY104 ZIP CODE 105 COUNTY 108 <br /> LODI CA 95240-1252 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107a <br /> 555593.540 1252 Not Collected <br /> 08a <br /> BUSINESS MAILING ADDRESS <br /> BUSINESS MAILING CITY 108 STATE I08c ZIP CODE 108d <br /> BUSINESS OPERATOR NAME log BUSINESS OPERATOR PHONE 110 <br /> JIM LOOCK 209-333-2556 <br /> 11. BUSINESS OWNER <br /> OWNER NAME(14) 111 1 OWNER PHONE(15) 112 <br /> JIM LOOCK/LOOCK LIVING TRUST 209-333.2556 <br /> 113 <br /> OWNER MAILING ADDRESS <br /> 423 1/2 POPLAR ST <br /> OWNER MAILING CITY 114 STATE IISZIPCODE 116 <br /> LODI CA 95240 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 CONTACT PHONE 118 <br /> JIM LOOCK 209 333 2556 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119a <br /> 4231/2 POPLAR ST spookyloockQsoftcommet <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> LODI CA 95420 <br /> IV. EMERGENCY CONTACTS <br /> NAME 123 NAME 128 <br /> JIM LOOCK N/A <br /> TITLE OPERATOR NN/A124 TITLE 129 <br /> BUSINESS PHONE 209-369-5387 125 BUSINESS PHONE N/A 130 <br /> 24-HOUR PHONE 209-333-2556 126 24-HOUR PHONE N/A 131 <br /> PAGER/CELL# 209 625 5147 127 PAGER/CELL# N/A 132 <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 informaiton submitted and <br /> believe the information is true,accurate,and com lere. <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 NAME OF DOCUMENT PREPARER 135 <br /> NAME OF SIGNER(print) 136 fITLE OF SIGNER 137 <br /> UPCF Rev. 12/2007 <br />