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UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATORIDENTIFICATION JAN - ' 2si0 <br /> SANUIN 0UW <br /> OFEEP'UI. IDENTIFICATION <br /> FACILITY ID# BEGINNING DATE 1ao. ENDING DATE lel. <br /> (Agency use only) - - 1=1/1/2010 12/31/2010 <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 Dr. ( ) <br /> BUSINESS SITE CITY w4. ZIP CODE 105. COUNTY m8. <br /> Stockton CA 95207 San Joaquin <br /> DUN&BRADSTREET 106, PRIMARY SIC 107. PRIMARY NAICS 107a. <br /> 00-734-7602 5541 <br /> BUSINESS MAILING ADDRESS 108.. <br /> P.O. Box 711 Attn: Environmental Department <br /> BUSINESS MAILING CITY 108b. I STATE 108'. ZIP CODE 108d. <br /> Dallas TX 75221 <br /> BUSINESS OPERATOR NAME 109. BUSINESS OPERATOR PHONE 110. <br /> Gur reet Mathara (209) 952-3543 <br /> H. BUSINESS OWNER <br /> OWNER NAME 111. OWNER PHONE 112. <br /> 7-Eleven, Inc. (800) 828-0711 <br /> OWNER MAILING ADDRESS 113. <br /> P.O. Box 711 Attn: Environmental Department <br /> OWNER MAILING CITY 114. 1 STATE 115. 1 ZIP CODE 116. <br /> Dallas TX 75221 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACTNAME 117. CONTACTPHONE 118, <br /> Ian Moorhead 916) 463-6776 <br /> CONTACT MAILING ADDRESS 119. CONTACT EMAIL 119x. <br /> P.O. Box 711 Attn: Environmental Department ian.moorhead@7-11.com <br /> CONTACT MAILING CITY IS. STATE 121. ZIP CODE 122. <br /> Dallas TX 75221 <br /> -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- <br /> NAME 123. NAME 128. <br /> Gur reet Mathara Dispatch I <br /> TITLE 1a. TITLE 129. <br /> Franchisee Emergency Service <br /> BUSINESS PHONE 125. BUSINESS PHONE 130. <br /> (209) 952-3543 800) 828-0711 <br /> 24-HOUR PHONE 126. 24-HOUR PHONE 131. <br /> (800) 828-0711 (800) 828-0711 <br /> PAGER# 127. PAGER# 132. <br /> (925) 479-9322 ( ) <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> Billing Address: P.O. Box 711 Attn: Environmental Department, Dallas, TX 75221-0711 <br /> Property Owner: 7-Eleven Inc. Phone No.: (800) 828-0711 <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 true,accurate,and complete. <br /> SIGNATURE OF OWNER/OPERATORJOR DESIONATED REPRESENTATIVE DATE 134. 1 NAME OF DOCUMENT PREPARER 135. <br /> Deanne Rotta <br /> NAME OF SIGNER(print) 136. TITLE OF SIGNER 13a. <br /> Ian Moorhead Environmental Compliance Mana er <br /> UPCF Rev. (1212007)-1/2 www.unidocs.org <br />