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SAN JOAQt 1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> LOP SITE FILE INFORMATION <br /> ', Local A c"enTose Onl <br /> Case# 0000887 <br /> Remedial fl e sight <br /> Site Name QUIK STOP MARKET#76 r7:Record ID 800000857 Y <br /> Location 1030 S OLIVE ST Site Record ID SD0000887 <br /> STOCKTON,CA 95215 Facility"Record ID FA0001060 s <br /> Phone Current Site Business QIJIK`_$tOP MARKETS#76 <br /> yzy ' y APN 157 <br /> �$ <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 /> Sian and return this form. <br /> Make changeslcorrections in RED ink or pencil. <br /> RESPONSIBLE PARTY INFORMATION RP INFORMATION CHANGE(date) <br /> PRI-RPhasbeen named a Primary RP. <br /> Business Name QUIK STOP MARKETS <br /> Contact MIKE KAVELOT <br /> Address 4567 ENTERPRISE ST <br /> F.REMONT,CA 95438-7605 <br /> Phone (510)657-8500 <br /> fl �I)o 7 3 <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 /> i <br /> REPRESENTING: <br /> SIGNATURE: Date '1 I <br /> Report#8021 Date 6/1512005 <br />