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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> c LOCAL OVERSIGHT PROGRAM. <br /> Responsible Party Information as of 6/15/2005 <br /> :l <br /> LOP SITE FILE INFORMATION <br /> l tical Ak <br /> Case# 1369eaey[ase Only <br /> Flrt []lltl Qtrrs€glt <br /> Site Name 7 ELEVEN#21756 A/2235* { 1i € 648 <br /> Location 853 E YOSEMITESite- tecorci I1300t1068 <br /> MANTECA,CA 95336 acdltylftcoiot'fiD1 A 4}1369 <br /> Phone 209-823-4310S "',3usiness )✓LIVEN x#21756 R12237* <br /> d APN C 23 32fl- 5 <br /> M <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 withthis <br /> site. If this billing information is not accurate, please mare necessary changes in the space provided,date, <br /> sign and return this form. <br /> ;. <br /> l <br /> Make changeslcorrections in RED ink or pencil. <br /> RESPONSIBLE PARTY INFORMATION RP INFORMATION CHANGE(date) <br /> I <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 95221-0711 <br /> Phone <br /> I <br /> l <br /> I <br /> j <br /> R Rooa��oa� <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')dentified 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 /> PRINTED NAME: TITLE: <br /> REPRESENTING: <br /> SIGNATURE: ': Date I 1 <br /> Report#8021 <� Date 6/15/2005 <br /> I <br />