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RECEWED <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> FACILITY INFORMATION MNJOAQUINCOLINN <br /> BUSINESS OWNER/OPERATOR IDENTIFICATIEOFEMERGENCY <br /> Page of <br /> I. IDENTIFICATION <br /> FACILITY ID# <br /> (Agency Use Only) BEGINNING DATE mo ENDING DATE 101. <br /> — — <br /> BUSINESSNAME(Same as Facility Name or DBA—Doing Business As) 3. BUSINESS PHONE 102. <br /> 7-Eleven # 32190 209 939-0679 <br /> BUSINESS SITE ADDRESS 103. BUSINESS FAX 102a <br /> 4943 S. STATE RT. 99 <br /> BUSINESS SITE CITY 1aa, <br /> ZIP CODE 105. COUNTY 108. <br /> Stockton CA 95215 <br /> u <br /> oa in <br /> DUN&BRADSTREET IN PRINIARYSIC 1oz PRSan JAIC <br /> IMARYNS iota <br /> 00-734-7602 5541 <br /> BUSINESS MAILING ADDRESS <br /> loss <br /> P.O. Box 711 Attn: Environmental Department <br /> BUSINESS MAILING CITY toes. STATE 1oso. ZIPCODE toed. <br /> Dallas TX 75221 <br /> BUSINESS OPERATOR NAME los. BUSINESS OPERATOR PHONE no. <br /> GILL, JIVTESH S. 209 939-0679 <br /> II. BUSINESS OWNER <br /> OWNER NAME 111. OWNER PHONE 112. <br /> 7-Eleven Inc. twnm 828-0711 <br /> OWNER MAILING ADDRESS m <br /> P.O. Box 711 Attn: Environmental Department <br /> OWNER MAILING CITY 114. 1 STATE us. <br /> ZIP CODE 116. <br /> Dallas TX 75221 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME uz CONTACTPHONE Its. <br /> Deanne Rotta 925 699-9795 <br /> CONTACT MAILING ADDRESS us. CONTACT EMAIL Tisa <br /> P.O. Box 711 Attn: Environmental De artment Deannne.Rotta@7-11.com <br /> CONTACT MAILING CITY 120. 1 STATE 1v. <br /> ZIP CODE 122. <br /> Dallas TX 75221 <br /> -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- <br /> NAME 123. NAME 128. <br /> GILL, JIVTESH S. Dispatch I <br /> TITLE 124 TITLE 129. <br /> Franchisee Emergency Service <br /> BUSINESS PHONE 125 BUSINESS PHONE 130, <br /> 209 939-0679 800 828-0711 <br /> 24-HOUR PHONE 126. 24-HOUR PHONE 131, <br /> 800 828-0711 800 828-0711 <br /> PAGER# 123 PAGER# 132. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> Billing Address: P.O. Box 711 Attn: Environmental Department, Dallas, TX 75221 <br /> Property Owner: FRIEDRICH ENTERPRISES LP Phone No.: O 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 true,accurate,and complete. <br /> SI TURE O OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 1x. NAME OF DOCUMENT PREPARER 135, <br /> 9/28/2010 Ste hen Bo d <br /> NAME OF SIGNER(print) 136. TITLE OF SIGNER 137. <br /> Ste hen Boyd for 7-Eleven Inc. Reg. Env. Comp. Mgr. <br /> UPCF Rev. (12/2007)-1/2 www.unidocs.org son Joagalo County DEB <br />