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'4 SAN JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> V <br /> LOP SITE FILE INFORMATION i; 3 <br /> Case# 0001505 !i m oo l .... e Only ... <br /> Fri' <br /> Site Name 7-ELEVEN#32262 �Reidt ► rerS'dtt�h# Qi1 <br /> RnR ' <br /> Location 2360 W GRANT LINE RD1 <br /> TRACY,CA 95367 Iatrtthtyte�10At77 <br /> Phone Fat ,%t l#utt l 7 ELEVi31 5I Q2G * : <br /> p��,tt pet'3 3A4 <br /> W 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 changes in the space provided,date, <br /> sig_n and return this form. <br /> Make changer./corrections 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 H <br /> Contact KEN HILLIARD <br /> Address P O BOX 711 <br /> �a <br /> DALLAS,TX 95221-0711 <br /> Phone <br /> i <br /> 11 <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 and/or Federal Laws. <br /> PRINTED NAME: 4TITLE: <br /> REPRESENTING: !I <br /> SIGNATURE: Date 1 I <br /> Report#8021 Date 6/15/2005 <br /> ,I <br /> i <br />