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q j <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM i <br /> Responsible Party Information as of 6/15/2005 <br /> LOP SITE FILE INFORMATION <br /> Case# 1 I 11 <br /> Site Name QUIK STOP MARKET#39 � � <br /> Location 2285 E FREMONT.ST s'- UA..' T OtlO42K <br /> STOCKTON,CA 95205Cllt td l t <br /> Phone 209-464-1038Utit„� <br /> ?}y 8 <br /> I <br /> The following information is currently on file with this Department. The Primary Responsible Party 1 <br /> identified below will be responsible for paymentW invoices for direct oversight charges associated with this J <br /> site. If this billing information is not accurate, please make necessary'changes in the space provided,date, <br /> sign and return this form. j <br /> Make changestcorrections in RED ink or pencil. <br /> RESPONSIBLE PARTY INFORMATION RP INFORMATION CHANGE(date) <br /> PRI-RP has been named a Primary.RP. <br /> Business Name QUIK STOP MARKETS <br /> Contact MIKE KAVELOT <br /> i <br /> Address 4567 ENTERPRISE ST <br /> FREMONT,CA' 95438-7605 <br /> Phone (510)657-8500 <br /> ,I <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 andlor Federal Laws, <br /> PRINTED NAME: TITLE: <br /> REPRESENTING: <br /> SIGNATURE: Date <br /> Report#8021 Date 6/15/2005 <br /> 4 <br />