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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# 13561A ede3se <br /> Site NameRrrtiCta1 CIetsht:: <br /> USA PETROLEUM CO <br /> Location 2500 W LODI AVEPl'+ irdt - <br /> LODI,CA 95240 y � ded9tyllSJt11i ` A31 '> <br /> Phone 209-333-9834 <br /> X1 111 1V$A OA90L*V#6 <br /> 13 'rt)~4 . <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 necessa than es in the space provided,date, <br /> sign and return this farm. <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 USA PETROLEUM COMPANY <br /> Contact CHARLES MILLER <br /> Address 30101 AGOURA CT.#204 <br /> AGOURA HILLS,CA 91301-4311 <br /> Phone (213)452-6200 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,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 1 I <br /> Report#8021 Date 6!15!2005 <br />