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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> I. IDENTIFICATION Page 2- of <br /> FACILITY ID# 1 BEGINNING DATE Ion ENDING DATE 101. <br /> (Agency Use Only) (/I O! 3. l�31/p-z— <br /> BUSINESS NAME(Same ss FACILITY NAME or DBA-Doing Business As) BUSINESS PHONE lm. <br /> oJz u CoQ-368-7/7/ 4eXF/57 <br /> BUSINESS SITE ADDRESS 103. <br /> 1129 S. SaEw�l sr <br /> CITYQ t 1a4. CA ZIP CODE 105. <br /> 9s�tFo <br /> DUN&BRADSTREET 106. SIC CODE(4 digit#) lm_ <br /> // AC13 37/7 30l0/ <br /> COUNTY IN. <br /> SGtn SdQ urn <br /> BUSINESS OPERATOR NAME 109. BUSINESS OPERATOR PHONE Ito. <br /> bQve sMl'q-h -9-0q-3&q-7171 <br /> IL BUSINESS OWNER <br /> OWNER NAME Ill. OWNER PHONE 112. <br /> -I' R, Dr buy oq--S& 17-7/ <br /> OWNER MAILING ADDRESS 113. <br /> if"w 00 <br /> CITY 114. STATE 115. ZIP CODE 116. <br /> 1-0 d e-A g53 l <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117. CONTACT PHONE us. <br /> ?-d eoo e-r I-o -3L8' 71 71 - T. /s3 <br /> CONTACT MAILING ADDRESS 119, <br /> CITY 120, STATE 121. ZIP CODE 122. <br /> Lod c14 9 sz1(- <br /> -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- <br /> NAME123. NAME 1211. <br /> r <br /> Fere 5 dru r 9tvY s'rnr <br /> TITLE 114, TITLE Ir9. <br /> 5-eLww,y- rU i6ti �1 r <br /> BUSINESS PHONE 125. BUSINESS PHONE 130. <br /> JLv q. 3&g. 7/ 7/ &-;I'7- /15/ o -3 [o -7 EXT 15/ <br /> 24-HOUR PHONE* 126. 24-HOUR PHONE* 131. <br /> a9 - 333 - 9-7S.2 o - 4503 <br /> PAGER# 12Z PAGER# 132o9 -s�lo- o z97 .2 Sip- 038Co <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> Property Owner: 1 h Phone No.: <br /> Billing Address: <br /> Certification: Based on to inqu' f�Amma4ndividuals responsible for obtaining the information,I certify under penalty of law that I have personally examined and <br /> am familiar with tied and belie a information is true,accurate,and complete. <br /> SIGNAT F(jrI�mPV&TOR2 DESIGN EPRESENTATIVE DATE j 134. NAME OF DOCUMENT PREPARER 135. <br /> Larso <br /> A ER v 136. TIME OF'SIGNER 131 <br /> *See Instructions on next page. <br /> UPCF hwR730(1/99)-1/2 http://www.unidom.org Rev.04/17/00 <br />