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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 <br /> Case# 1780 Local Agency Use Only <br /> Site Name CHEVRON USA#9-4054 former Remedial Oversight <br /> ( ) Record ID 800000635 L/� <br /> Location 2103 COUNTRY CLUB BLVD Site Record ID SD0000635 <br /> STOCKTON,CA 95204 Facility Record ID FA0005220 <br /> Phone 925-842-9655 Current Site Business CHEVRON#9-4054 <br /> APN 123-080-29 <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) C /3dOS' <br /> PRI- RP has been named a Primary RP. <br /> Business Name CHEVRON TEXACO COMPANY ^C�e�rOn �CNVlrrmyyx..vl�al �tn� ��' Co <br /> Contact DARIN ROUSE v . L <br /> Address PO BOX 6012 K2260 ( a)I ?68r rnSGr 40✓t l K 22b b <br /> SAN RAMON,CA 94583 ScqA�awinA I C.A 94 S-11 <br /> Phone R2S g4 2 15 }Z <br /> Other RP Address D BLDG V <br /> SAN RAMf1N ('e odcu+ <br /> -P, oo ag-a <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: L r10uSL TITLE: f roXj— <br /> REPRESENTING ^L ' <br /> SIGN RE: is Date G 150 <br /> Report#8021 Date 6/15/2005 <br />