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r i <br /> iILI <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> i <br /> LOP SITE FILE INFORMATION <br /> I <br /> Case# 1112 i F �� Loc L Ageftcy fl e Only <br /> 4 <br /> Site Name QUIK STOP MARKET#39 a ehiddial,QvWrstgk x D 42g <br /> i fteGCsfd - <br /> Location 2285 E FREMA. <br /> OIVT ST I`ve ltxrclll�? ;) `{ q <br /> STOCKTON,CA 95205 FaA000163 <br /> Phone 209-464-1038 ° £ti nt s rr t ►r es ; Qz�K S,'T" 3 <br /> The following information is currently on file with this Department. The Primary Responsible Party <br /> i1 I <br /> identified below will be responsible for payment of invoices for direct oversight charges associated with this <br /> ,i <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 /> RESPONSIBLE PARTY INFORMATION Make INFORMATION <br /> CHANGE <br /> in RED ink or pencil <br /> �; RP INFORMATION CHANGE(date) <br /> II <br /> PRI-RP has been named a Primary RP. <br /> Business Name QUIK STOP MARKETS <br /> I <br /> Contact MIKE KAVELOT <br /> Address <br /> 4567 ENTERPRISE ST <br /> ,l <br /> FREMONT,CA;Y5438-7605 <br /> i <br /> Phone (510)657-8500 k <br /> 1J <br /> 'a <br /> ;i <br /> i <br /> I <br /> 1 <br /> i <br /> F <br /> D �V75. <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owrer,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 /> E i <br /> PRINTED NAME: TITLE: <br /> REPRESENTING: <br /> SIGNATURE: Date <br /> I <br /> Report#8021 Date 6/15/2005 <br /> E <br /> } <br /> :I r <br />