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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNERIOPERATOR IDENTIFICATION <br /> Pae 2 ofS <br /> I. IDENTIFICATION <br /> FACILITY ID# 1 BEGINNING DATE 100. 1 ENDING DATE 101• <br /> (Agency Use Only) <br /> I1/01/10 10/31/11 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 1 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 108. <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 111 <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 145040 <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# 13z. <br /> N/A ' N/A <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> Property Owner: Phone No.: <br /> Billing Address: <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 ipformatio mi and believe the information is true,accurate,and complete. <br /> SIGNA;SIGNER <br /> F OP TOR E GNATED REPRESENTATIVE DATE 134. NAME OF DOCUMENT PREPARER 135. <br /> Grace Haggard <br /> NAME (print) 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 />