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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM _ <br /> Responsible Party Information as of 6/15/2005 Y <br /> LOP SITE FILE INFORMATION <br /> ----- <br /> Case# 1369 3 c en �[75e Only <br /> Site Name * ftetrtilaNt+ers; 6t <br /> �: , <br /> 7 ELEVEN#21756 A/2235 }'{���{p RC}UE1Q©648:: <br /> Location 853 E YOSEMITEcordl1pUtIG48 <br /> MANTECA,CA 95336 3FA0001359 <br /> Phone 209-823-4310 Ctarrrtite.;3ustrs1✓LEVIit+t1755B.t'223 *., <br /> A�?N 223-3b 15,,. <br /> The following information is currently on fle with this Department'. The Primary Responsible Party i 1 <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 cFianges/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 N—IiIi�1�rRD� ?,",I <br /> 'k J a i 1r� c,J-x��—�1 o/L I -e— <br /> Address P-0-BOX-711`" ude <br /> 4)A-LIAS,Tx 95221-4711— t d . S a l�l ce ru s le 0 <br /> Phone <br /> I <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. <br /> Kea � MGR, ENVIRONMENTAL SEMCI"S <br /> PRINTED NAME: TITLE. <br /> 7-ELEVEN. ING. <br /> REPRESENTING: i <br /> SIGNATURE: I Date 1 I <br /> Report#8021 �� Dale 6/15/2005 <br />