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no <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM2005 <br /> JUL 1 4 <br /> Responsible Party Information as of 6/15/2005 ENVIRONMENT HEAL H <br /> L' <br /> LOP SITE FILE INFORMATION <br /> Case# 1073 � e s�0 <br /> y. <br /> Site Name 7 ELEVEN STORE#14117 D/2237 R t mor I �UbOI ' <br /> Location 2725 COUNTRY CLUB BLVD I e Record �3 <br /> STOCKTON,CA 95204 crlltyRe �IDt364 <br /> Phone 209-463-1259 0RE#11 %22 _ <br /> APN 21-2-, <br /> IF <br /> --- - -= -r' -- - "F ----=--------------- <br /> -= --- ---- ---------- <br /> The following information is currently on file with'this Department. The Primary_Responsible Party f <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 /> r <br /> ; sign and return this form. r <br /> Make changes/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 7-ELEVEN / r <br /> Contact +kEN HILL-I-ARD— ��D 0-4- — LA U CJ-i+`�(-1 6 n I <br /> Address -P-0-BOX-7-1-1 s 6 co2 �►t'1-fir <br /> DA-L-L-AS,T,X_9522_1-071 i ' s0 I-) �low f e. Z, E e. ( b <br /> Phone f do 0,a (7k <br /> -- L7 <br /> yam. <br />�4 <br /> air <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. j <br /> PRINTED NAME: TITLE: <br /> illiard MGR, ENVIRONMENTAL SERVICES <br /> li <br /> REPRESENTING: 7-E EN$ ING-- <br /> SIGNATURE: Date <br /> 1 <br /> I <br /> Report#8021 Date 6/15/2005 <br /> i <br />