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BUSINESS IDENTIFICATION FORM • Page 1 of 3 <br />Main Menu <br />BUSINESS OWNER/OPERATOR IDENTIFICATION <br />ACCOUNT#: <br />12169 <br />DATA ENTRY <br />I. IDENTIFICATION <br />BUSINESS NAME (4)ULTRACARE OF STOCKTON BUSINESS PHONE NUMBER (5) 209-957-7841 <br />SITE ADDRESS (6) <br />4629 N WEST LN <br />STE #10 <br />STREET NO DIRECTION STREET NAME STREET TYPE APPT/BLDG/SUITE <br />CITY (7) <br />STOCKTON STATE(8) CA <br />ZIP (9) 95210 <br />DUN & <br />BRADSTREET(10) <br />93-963-3384 SIC CODE (4 DIGIT #)(11) <br />7538 <br />OPERATOR <br />NAME (12) <br />RICKY K CHAM OPERATOR PHONE (13) <br />209-957-7841 <br />II. BUSINESS OWNER <br />OWNER NAME (14) <br />RICKY K CHAM OWNER PHONE (15) <br />209-957-7841 <br />OWNER ADDRESS (16) <br />CITY (17) <br />STATE (18) <br />ZIP (19) <br />III. ENVIRONMENTAL CONTACT <br />CONTACT NAME (20) <br />RICKY K CHAM CONTACT PHONE (21) <br />209-609-0478 CELL <br />CONTACT ADDRESS <br />(22) STREET DIRECTIONSTREET NAMESTREET TYPEAPPT/BLDG/SUIT <br />If different from <br />NUMBER <br />#6 or #41 <br />CITY (23) <br />STATE (24) <br />ZIP (25) <br />IV. EMERGENCY CONTACTS <br />SECONDARY <br />PRIMARY <br />NAME (31) <br />SISOUPHANH <br />NAME (26) <br />RICKY K CHAM <br />INTHAVILAYSUK <br />TITLE (27) <br />OWNER <br />TITLE (32) <br />TECHNICIAN <br />BUSINESS <br />209-957-7841 <br />BUSINESS <br />209-957-7841 <br />PHONE (28) <br />PHONE (33) <br />24 HOUR <br />209-477-3839 HOME <br />24 HOUR <br />209-957-1395 <br />PHONE (29) <br />PHONE (34) <br />(AFTER BUSINESS HOURS) <br />(AFTER BUSINESS <br />HOURS) <br />http://sjoesdata.org/oes_hmmp/section_tables/CHMIRF_ps_review.lasso?-Database=tran... 12/28/2009 <br />