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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Pae Of <br /> I. IDENTIFICATION <br /> FACILITY ID# 1. BEGINNING DATE 100 1 ENDING DATE 101. <br /> (Agency Use Only) <br /> BUSINESS NAME(S>as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102. <br /> frJ L -' � C <br /> BUSINESS SIT ADDRESS V103. <br /> 9-tot5 C-1N3 <br /> 104. ZIP CODE los. <br /> crrY CA <br /> n <br /> DUN&BRADS REET lOf. SIC CODE(4 digit#) 107. <br /> los. <br /> COUNTY <br /> u� Ll <br /> BUSINESS OPERATOR NAME 109. BUSINESS OPERATOR PHONE 110. <br /> II. BUSINESS OWNER <br /> OWNER NAME 111. OWNER PHONE 112. <br /> \lc�' - -73 <br /> 113. <br /> OWNER MAILING ADDRESS <br /> t t <br /> 114. STATE 115. ZIP CODE 116. <br /> CITY 0-pr 4 -59 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117. CONTACT PHONE 118. <br /> 119. <br /> CONTACT MAILING ADDRESS <br /> CITY Izo. STATE 121 ZIP CODE 122. <br /> -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- <br /> ME + 123. NAME 125. <br /> A*Ar `i <br /> TITLE 124. TITLE 129. <br /> AIVA Gi 59, MAN Aa ap, <br /> BUSINESS PHONE 125. BUSINESS PHONE 13°. <br /> (CM ;1- 7,31-9 x <br /> 24-HO PHONE* 126. 24-HOUR ONE* 131. <br /> C° g�-dtea- CScd 3W-5- o <br /> PAGER# 127. PAGER# 132. <br /> 133. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: l <br /> Property Owner:T V 1 1 Phone No.: N :� 2-73)9 <br /> Billing Address: 1(l I ' IiO JG` vt t�.��'�cX1 SCA <br /> Certification: Based on my inquiry of those individuals responsible for obtaining the information,I certify under penalty of law that I have personally examined and <br /> am familiar with the information submitted and believe the information is true,accurate,and complete. <br /> We.e1nstr.uctis.n-nextp5ge. <br /> TO DESIGNATED REPRESENTATIVE D�E�O � 134. NAME OF DOCUMENT PREP,*ER \ 135. <br /> 136. TITLE OF SIG ER [e 137. <br /> ' 6 <br /> koull <br /> UN-020-5/17 wwis.unidocs.org Rev.01/16/02 <br />