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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> r <br /> I LOCAL OVERSIGHT PROGRAM <br /> L. Responsible Party Information as of 6/15/2005 <br /> i <br /> I <br /> a <br /> LOP SITE FILE INFORMATION <br /> g qe Yy--y7-- <br /> 77-777','0' <br /> -7 <br /> 69, if lJiu� <br /> Case# 1369 y <br /> e sr3iatQare�rstg # � <br /> Site Name 7 ELEVEN 421756 A/2235* R 't <br /> 4ecr�1L) <br /> Location O 648 �i <br /> 853 E YOSEMITE _ - <br /> aclllBCbtY1 IC) A <br /> MANTECA,CA 95336 <br /> Phone 209-823-4310 ufr+? t tte t slness ,7 -VEN 21'Z 6 8 2237* <br /> The following information is currently on file with this Department.'I The Primary Responsible Party E <br /> i <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 /> {fi <br /> Make changes/corrections in RED ink or pencil. } <br /> RESPONSIBLE PARTY INFORMATION RP INFORMATION CHANGE=(date) I <br /> PRI-RP-has been named a Primary-RP. <br /> Business Name 7-ELEVEN ! <br /> Contact KEN HILLIARD <br /> Address P O BOX 711 I <br /> DALLAS,TX 95221-0711 <br /> i <br /> Phone <br /> j <br /> r <br /> I <br /> i <br /> i E <br /> k <br /> t <br /> r <br /> I kk� <br /> , <br /> i <br /> f <br /> 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 Ordinacetodes and/or Standards and State and/or Federal Laws. <br /> PRINTED NAME: TITLE- <br /> REPRESENTING:— <br /> SIGNATURE: <br /> LE:REPRESENTING:SIGNATURE: Date / <br /> Report#8021 I Date 6/15/2005 <br /> �l <br /> �� I <br />