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i <br /> M SAN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> LOP SITE FILE INFORMATION <br /> Case # 1070 Local Agency Use Only <br /> Remedial Oversight <br /> Site Name <br /> SHELL OIL COMPANY-EQUIVA Record ID R00000484 <br /> Location 2575 COUNTRY CLUB BLVD Site Record ID SD0000484 <br /> STOCKTON, CA 95204 Facility Record ID FA0006439 <br /> Phone 209-948-0574 Current Site Business COUNTRY CLUB SHELL* <br /> APN 123-020- 12 <br /> The following information is currently on file with this Department. The Primary Responsible Partv <br /> identified below will be responsible for payment of invoices for direct oversight charges associated with this <br /> 1 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 SHELL OIL PRODUCTS US <br /> Contact DENIS L BROWN <br /> Address 20945S WILMINGTON AVE <br /> CARSON, CA 90810-1039 <br /> Phone <br /> ACR ex) a4s (4p S <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 />