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0 0 RECEIVED � <br /> �n� OCT - 7 2010 <br /> UNIFIED PROGRAM CONSOLIDATED FORM SAN JOAQUIN COUNTy <br /> FACILITY INFORMATION OICEOFEMERSENCy VIC <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Page of <br /> I. IDENTIFICATION <br /> FACILITY ID p 1_ BEGINNING DATE "o ENDING DATE 101. <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3. BUSINESS PHONE 102. <br /> 7-Eleven# 20632 209 952-3543 <br /> BUSINESS SITE ADDRESS 103. BUSINESS FAX 102. <br /> 4627 DA VINCI DRIVE <br /> BUSINESS SITE CITY104. ZIP CODE 105. COUNTY las. <br /> Stockton CA 95207 San Joaquin <br /> DUN&BR A DSTREET la. PRIMARY SIC 107. PRIMARY NAICS lora <br /> 00-734-7602 5541 <br /> BUSINESS MAILING ADDRESS 108a <br /> P.O. Box 711 Attn: Environmental Department <br /> BUSINESS MAILING CITY loan STATE 108� ZIP CODE 108d. <br /> Dallas TX 75221 <br /> BUSINESS OPERATOR NAME 109 1 BUSINESS OPERATOR PHONE 110. <br /> MATHARU, GURPREET 209 952-3543 <br /> II. BUSINESS OWNER <br /> OWNER NAME111. OWNER PHONE 112. <br /> 7-Eleven Inc. 0(800) 828-0711 <br /> OWNER MAILING ADDRESS 113. <br /> P.O. Box 711 Attn: Environmental Department <br /> OWNER MAILING CITY 114. STATE 115 1 ZIP CODE 115. <br /> Dallas I TX 75221 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117, CONTACTPHONE us. <br /> Deanne Rotta 925 699-9795 <br /> CONTACT MAILING ADDRESS 119. CONTACT EMAIL 119. <br /> P.O. Box 711 Attn: Environmental Department Deannne.Rotta@7-11.com <br /> CONTACT MAILING CITY 120- STATE 121. ZIP CODE 122. <br /> Dallas TX 75221 <br /> -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- <br /> NAME 123_ NAME 128. <br /> MATHARU, GURPREET Dispatch I <br /> TITLE 124, TITLE 129. <br /> Franchisee Emergency Service <br /> BUSINESS PHONE 12s. BUSINESS PHONE 130_ <br /> 209 952-3543 800 828-0711 <br /> 24-HOUR PHONE 125. 24-HOUR PHONE 131. <br /> 800 828-0711 800 828-0711 <br /> PAGER H 127. PAGER 4 132. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> Billing Address: P.O. Box 711 Attn: Environmental Department, Dallas, TX 75221 <br /> Property Owner: HOWARD N&C ANTOINETTE SWEET BLANKENSHIP Phone No.: ()Unknown <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 we,accurate,and complete. <br /> SI ATUREO OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE IN NAME OF DOCUMENT PREPARES 135. <br /> 9/28/2010 Stephen Boyd <br /> NAME OF SIGNER(print) 135. 1 TITLE OF SIGNER 132 <br /> Stephen Boyd for 7-Eleven Inc. Reg. Env. Comp. M r. <br /> UPCF Rev. (1212007)-112 www.unidocs.org San doaqulo County DEH <br />