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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: 03/25/2008 Page of <br /> I. IDENTIFICATION <br /> FACILITY ID# 9625 1 1 BEGINNING DATE N/A 100 1 ENDING DATE N/A <br /> 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 10? <br /> JK AUTOMOTIVE REPAIR 209-825-7340 <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX <br /> 710 E YOSEMITE AVE Not Collected <br /> BUSINESS SITE CITY104 ZIP CODE 105 COUNTY 108 <br /> MANTECA CA 95336-5827 SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS 107 <br /> APPLIED FOR 7539 Not Collected <br /> BUSINESS MAILING ADDRESS 108 <br /> BUSINESS MAILING CITY 108t STATE 108c ZIP CODE 108d <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 1 10 <br /> N/A N/A <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) 111 1 OWNER PHONE(15) 112 <br /> DAVID GARZA 209-825-7340 <br /> OWNER MAILING ADDRESS 113 <br /> 710 E YOSEMITE <br /> OWNER MAILING CITY 114 STATE 115 ZIP CODE 116 <br /> MANTECA CA 95336 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117 1 CONTACT PHONE 118 <br /> DAVID GARZA 209-825-7340 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119 <br /> quicksmogs@aol.com <br /> CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 <br /> IV. EMERGENCY CONTACTS <br /> NAME DAVID GARZA 123 NAME RALPH GARZA 128 <br /> TITLE 124 TITLE 129 <br /> OWNER CONTACT <br /> BUSINESS PHONE 209-825-7340 125 BUSINESS PHONE 209-825-7340 130 <br /> 24-HOUR PHONE 209-838-2621 126 24-HOUR PHONE 209-838-9943 131 <br /> PAGER/CELL# N/A 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,1 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 complete. <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 1 NAME OF DOCUMENT PREPARER 135 <br /> NANI F OF SIGNER(print) 136 TITLE OF SIGNER 137 <br /> UPCF Rev. 12/2007 <br />