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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> LOP SITE FILE INFORMATION <br /> Case# 1074 <br /> Site Name 7 ELEVEN STORE#20632 B/2235 1 <br /> Location 4627 DA VINCI DR <br /> STOCKTON,CA 95207 <br /> Phone 209-952-3543 <br /> The following information is currently on file with this Department. The Primary Responsible Party <br /> identified below will be responsible for payment of invoices for direct oversight charges associated with this <br /> site. If this billing information is not accurate, please make necessary chanes in the space provided,date, <br /> sign and return this form. . <br /> Make changes/corrections in RED ink or pencil. <br /> RESPONSIBLE PARTY INFORMATION RP INFORMATION CHANGE(date) <br /> PRI-RP has been named a Primary R.P. <br /> Business Name 7-ELEVEN <br /> Contact KEN HILLIARD <br /> Address P O BOX 711 <br /> DALLAS,TX 95221-0711 <br /> Phone <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator,primary responsible party,or agent of same,acknowledge that all <br /> site,and/or project specific,EHD hourly charges associated with this site will be billed to the party identified as the PRIMARY RESPONSIBLE PARTY on this <br /> form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> PRINTED NAME: TITLE: <br /> REPRESENTING: <br /> SIGNATURE: Date <br /> Report#8021 Date 6/15/2005 <br />