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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> LOP SITE FILE INFORMATION 35,2 <br /> Case# 1073ad Sn <br /> erg 101 All t. i <br /> Site Name 7 ELEVEN STORE#14117 D/2237 <br /> Rc�r� <" <br /> Location 2725 COUNTRY CLUB BLVD 51teRe cerci�' <br /> STOCKTON,CA 95204rallty `ecorcl FAOOf� � <br /> Phone 209-463-1259t�rrent Slte Buslnes5n141170/223 <br /> APN1 (} y <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 /> sign and return this form. <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 <br /> Contact KEN HILLIARD <br /> Address P O BOX 711 �( <br /> DALLAS,TX 25221-0711 <br /> Phone <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 Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> PRINTED NAME: TITLE: <br /> REPRESENTING: <br /> SIGNATURE: Date <br /> Report#8021 Date 6/15/2005 <br />