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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 /> y <br /> Lcoal Aenc+:OseflnlY <br /> Case# 0001505 P. rtliat �srgk�t� $ <br /> Site Name 7-ELEVEN#32262 ;� r�i R � r <br /> Location 2360 W GRANT LINE RD Fr�l1T3 500 <br /> [I15 <br /> TRACY,CA 95367 ac(Ir r to EATS ; <br /> � <br /> Phone Ctfrrertt Sustn 7 ELIa EN S T CISi22*** <br /> The following information is currently on file with this Department. The Prim=provided, <br /> identified below will be responsible for payment of invoices for direct oversighith this <br /> site. If this billing information is not accurate, please make necessary changes date, <br /> sign and return this form. <br /> Make changeslcorrections 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 7-ELEVEN <br /> Contact Ch1-ARD- ( 1 C�`t c�, " �-r + 0 f1 I <br /> Address p'OnOX-711- �= -Urn F�r v1•� t_rs nr+� <br /> -DAC-mss,Tx 95221-0711 3 0{�1 S c� 0 �} <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,EFID 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: Hilliard TITLE: MGR, ENVIRONMENTAL SERVICES <br /> REPRESENTIN 7-El N` INC. <br /> SIGNATURE: �— Date <br /> 7 1ir 1 <br /> Report#8021 Date 6/15/2005 <br />