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—"MR <br /> 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Pae 2 of 13 <br /> I. IDENTIFICATION <br /> FACILITY ID# 1 BEGINNING DATE 100 ENDING DATE 101. <br /> (Agency Use Only) 11/01/10 110/31/11 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. BUSINESS PHONE 102 <br /> LENSCRAFTERS#135 (209)477-9914 <br /> BUSINESS SITE ADDRESS 103. <br /> 4950 PACIFIC AVE. <br /> CITY 104. ZIP CODE los. <br /> STOCKTON CA 95207 <br /> DUN&BRADSTREET 106. SIC CODE(4 digit#) 107. <br /> 779-1013642 5995 <br /> COUNTY los. <br /> San Joaquin <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110. <br /> Lenscrafters,Inc. (513)765-6000 <br /> II. BUSINESS OWNER <br /> OWNER NAME 111. OWNER PHONE 112. <br /> Lenscrafters,Inc. (513)765-6000 <br /> OWNER MAILING ADDRESS 113, <br /> 4000 Luxottica Place <br /> CITY 114. STATE 115. ZIP CODE 116. <br /> Mason OH 45040 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117, CONTACT PHONE 118. <br /> Rob Robison (513)765-6274 <br /> CONTACT MAILING ADDRESS 119 <br /> 4000 Luxottica Place <br /> CITY 120 STATE 121 ZIP CODE 122, <br /> Mason OH 45040 <br /> -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- <br /> NAME 123. NAME 128, <br /> RAYMUND NOEL ERIC BRIGHT <br /> TITLE 124_ TITLE 129, <br /> General Manager Regional Quality Coordinator <br /> BUSINESS PHONE 125. BUSINESS PHONE 130. <br /> (209)477-9914 (916)535-1686 <br /> 24-HOUR PHONE* 126. 24-HOUR PHONE* 131. <br /> (209)263-1594 (916)475-5081 <br /> PAGER# 127 PAGER# 132. <br /> N/A N/A <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> Property Owner: Phone No.: <br /> Billing Address: <br /> Certification: Based on uiry 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' ormatio submitte a ve the information is true,accurate,and complete. <br /> SIGNATURE OF O ER/ A R O ES E EPRESENTATIVE D76P;-z1,0A61,,0 <br /> 134, NAME OF DOCUMENT PREPARER 135, <br /> I Grace Haggard <br /> NAME OF SIGNS rint) 136. TITLE OF SIGNER 137 <br /> Rob Robison Senior Manager of Safety and Environmental Affairs <br /> *See Instructions on next page. <br /> UN-020-4/17 www.unidocs.org Rev.01/16/02 <br />