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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 <br /> � <br /> Case# 1430 r c / gticyTJsti 01t1�r ' <br /> � <br /> Site Name QUIK STOP MARKET#121 _ IpRO00fl5 f � <br /> fr <br /> Location 1196 W LOUISE AVE <br /> a <br /> MANTECA,CA 95336 ., dI FenrdIt �A €1$z}$ <br /> Phone 209-239-2957 t1 nt'v e itthe z r <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 change's/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 95438-7605 <br /> Phone (510)657-8500 <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. 1 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 />