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UNIFIED PROGRAM CONSOLIDATED FO <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Modification Date:05/07/2009 <br /> Last Website Update: 2/05/2009 Page of <br /> I. IDENTIFICATION <br /> FACILITY.ID# 5078 1 BEGINNING DATE NIA 100 ENDING DATE NIA 101 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS PHONE 102 <br /> SEVEN ELEVEN#20632 204-952-3543 <br /> BUSINESS SITE ADDRESS 103 BUSINESS FAX <br /> 4627 DA VINCI DR Not Collected <br /> BUSINESS SITE CITY104 ZIP CODE 105 COUNTY 108 <br /> STOCKTON CA 95207 . SAN JOAQUIN <br /> DUN&BRADSTREET 106 PRIMARY SIC 107 PRIMARY NAICS- 107a <br /> 00-7347602 5541 Not Collected <br /> BUSINESS MAILING ADDRESS 108a <br /> P.O.BOX 711 <br /> BUSINESS MAILING CITY 108 STATE 108c ZIP CODF 108d <br /> DALLAS TX 75221-0711 <br /> BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 <br /> MANJIT&GURPAL GREWAL 209-952-3543 <br /> 11. BUSINESS OWNER <br /> OWNER NAME(14) -111 OWNER PHONE(15) 112 <br /> 7-ELEVEN INC ATTN GASOLINE 800-828-0711 <br /> OWNER MAILING ADDRESS 113 <br /> P.O.BOX 711 <br /> OWNER MAILING CITY 114 STATE 1 IS ZIP CODE 116 <br /> DALLAS TX 95221 <br /> 111. ENVIRONMENTAL CONTACT <br /> CONTACT NAME - 117 CONTACT PHONE 118 <br /> IAN MOORHEAD 916-463-6776 <br /> CONTACT MAILING ADDRESS 119 CONTACT EMAIL 119a <br /> P.O.BOX 711- ian.moorhead@7-1I.com <br /> CONTACT MAILING CITY^ 120 STATE 121 ZIP CODE 122 <br /> DALLAS TX 75221-0711 <br /> IV. EMERGENCY CONTACTS' <br /> NAME 123 NAME 128 <br /> MANJIT GREWAL DISPATCH 1 1 <br /> TITLE I FRANCHISEE 124 TITLE 129 <br /> EMERGENCY SERVICES <br /> BUSINESS PHONE 130 <br /> 209-952-3543 125 BUSINESS PHONE 800-828-0711 <br /> 24-HOUR PHONE 800-828-0711 126 24-1-JOUR PHONE 800-828-0711 131- <br /> PAGER# N/A 127 PAGER# N/A 132 <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION:. 133 <br /> COMPLETE PAGE 2 OF BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> Certification: Based on my inquiry of those individuals responsible for obtaining the information,I certify under penalty of law by signing below or certifying by the <br /> established processes on the Administerting Agency's HMMP Compliance Website that I have personally examined and am familiar with the infomtaiton submitted and <br /> believe the information is true,accurate,and complete. <br /> SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134 1 NAME OF DOCUMENT PREPARER 135 <br /> NAME OF SIGNER(print) 136 TITLE OF SIGNER 137 <br /> UPCF(Rev•1212007) <br />