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UNIFIED PROGRAM CONSOLIDATED FORM RECEIVED <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION , _ <br /> Pae of <br /> I. IDENTIFICATIONOFFICE OF EMERGENCY GERVIOng <br /> FACILITY R)# 1. BEGINNING DATE 100 ENDING DATE 101. <br /> (Agency Use only) - - 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 # 32190 209 939-0679 <br /> 4943 S. Highway 99 <br /> BUSINESS SITE ADDRESS 103. BUSINESS FAX 102a. <br /> ( ) <br /> BUSINESS SITE CITY 1oa. <br /> ZIP CODE 103 COUNTY 105. <br /> Stockton CA 95215 San Joa uin <br /> DUN&BDSTREET lab. PRIMARY SIC lm. PRIMARY NAICS <br /> RPRIMARY laza. <br /> 00-734-7602 5541 <br /> BUSINESS MAILING ADDRESS 108.. <br /> P.O. Box 711 Attn: Environmental Department <br /> BUSINESS MAILING CITY 1086. STATE 10& ZIP CODE 10sa. <br /> Dallas TX 75221 <br /> BUSINESS OPERATOR NAME 109. BUSINESS OPERATOR PHONE Ito. <br /> Jivtesh Gill (209) 939-0679 <br /> II. BUSINESS OWNER <br /> OWNERNAME 11L OWNERPHONE t1z. <br /> 7-Eleven, Inc. (800) 828-0711 <br /> OWNER MAILING ADDRESS 113 <br /> P.O. Box 711 Attn: Environmental Department <br /> OWNER MAILING CfI'Y 114. STATE 115. ZIP CODE 116. <br /> Dallas TX 75221 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME ua. CONTACTPHONE us. <br /> Ian Moorhead (916) 463-6776 <br /> CONTACT MAILING ADDRESS 1I9. CONTACT EMAIL u9a. <br /> P.O. Box 711 Attn: Environmental Department ian.moorhead@7-11.com <br /> CONTACT MAILING CITY 120. 1 STATE 121. ZIP CODE ln. <br /> Dallas TX 75221 <br /> -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- <br /> NAME 123. NAME 128. <br /> Jivtesh Gill Dispatch I <br /> TITLE ��. TITLE 129. <br /> Franchisee Emergency Service <br /> BUSINESS PHONE Iss. 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# 117. PAGER# 132. <br /> ( ) ( ) <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> BiilingAddress: 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 We,accurate,and complete, <br /> SIGNATURE OF OWNER/OPERATOR OR DESIG D REPRESF.NTATIVE DATE D4. NAME OF DOCUMENT PREPARER 135. <br /> Zhu 140 Deanne Rotta <br /> NAME OF SIGNER(print) 136. TITLE OF SIGNER 137. <br /> Ian Moorhead Environmental Compliance Mana er <br /> UPCF Rev. (12(2007)-1/2 www.unidomorg <br />