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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 /> ��� � G.nca].A'ketiCV'L73G�113Y <br /> Case# 1130 '_ <br /> Reriletlial Oversight <br /> Site Name QUIK STOP MARKET#132 Record Ip 800000427 <br /> Location3555 W HAMMER LN - SOeReC rd ID SDO000427 <br /> STOCKTON,CA 95209 £aCility,Rectud ID PA0002232 <br /> Phone 209-951-3195 Gs/trettt Sde Rtlaipses QUIK STOP MARKETS#132' S <br /> 9' <br /> AM 07318020 <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 changes 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 RP. <br /> Business Name QUIK STOP MARKETS <br /> Contact MIKE KAVELOT <br /> Address 4567 ENTERPRISE ST <br /> FREMONT,CA 9y38-$05 <br /> 6 6 S <br /> Phone (510)657-8500 1 <br /> ft 40,L.A-1 y <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 Ordinate 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 />