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BUSINESS OWNERIOPERATO -1 AT ON,FORD Account#: 5078 <br /> Ll <br /> I. IDENTIFICATION <br /> BUSINESS NAME (4) SEVEN ELEVEN #20632 BUSINESS PHONE(5) 1209-952-3543 <br /> SITE ADDRESS (6) 14627 ❑ DA VINCI 11DR <br /> Street No. Direction Street Name Street Type Apt/Bldg/Suite <br /> CITY (7) ISTOCKTON STATE(8) CA ZIP(9)F95207 <br /> DUN & (10) 00-734-7602 SIC CODE(4 DIGIT#) (11) 5541 <br /> BRADSTREEI <br /> OPERATOR (12) MANJIT & GURPAL OPERATOR PHONE(13) <br /> NAME GRE WAL 209-952-3543 <br /> II. BUSINESS OWNER <br /> OWNER NAME(14) 7-ELEVEN INC ATTN OWNER PHONE(15) 253-796-7170 <br /> GASOLINE ACCTG <br /> OWNER MAILING ADDRESS(16) <br /> (If different from site address) F 0. BOX 711 <br /> CITY(17) DALLAS STATE(18) TX ZIP(19) 195221 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME(20) RANDY MARTIN CONTACT PHONE(21> 253-796-7170 <br /> MAILING ADDRESS(22) P.O. BOX 711-GASOLINE <br /> (If different from business ACCTG <br /> mailing address) 11 <br /> Street No. Direction Street Name Street Te Apt/Bldg/Suite <br /> CITY(23) STATE(24) ZIP(25) <br /> ELS TX 75221-0711 <br /> Primary IV. EMERGENCY CONTACTS Secondary <br /> NAME(26) DISPATCH I NAME(31) DISPATCH 1 <br /> TITLE(27) EMERGENCY SVCS TITLE(32).,EMERGENCY SERVICES <br /> BUSINESS PHONE(28)1800-828-0711 BUSINESS PHONE(33) 1800-828-0711 <br /> 24-HOUR PHONE(29) 800-828-0711 24-HOUR PHONE(34) 500-828-0711 <br /> PAGER#(30) NSA PAGER#(35) NIA <br /> EXTREMELY HAZARDOUS SUBSTANCES (EHS) <br /> ON-SITE EHS (36) NO If yes,and above Threshold Planning Quantities,attach a sheet of paper with a general <br /> description of the process and principle equipment involving the EHS. <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION(37) Provide information requested on the back of this form <br /> NAME OF DOCUMENT PREPARER(38) RACHEL RODRIGUEZ <br /> NAME OF OWNER/OPERATOR(39) RANDY MARTIN- DATE(40) <br /> ENVIRONMENTAL MGR, <br /> DATE REC'D: 8/15106 <br /> 1 <br />