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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 /> Racal Auencv Use Ontu �x 0V i Z <br /> / <br /> Case# 1669 <br /> Site Name USA GASOLINE CORP 4110 <br /> Location 2132 MARIPOSA RD <br /> STOCKTON,CA 95206 <br /> CaCiYk2 � P�1Ob & ; errs,, i <br /> C(jfhtaflt051nd5s 11$AQ�� 1 ' ; Q <br /> Phone 213-452-6200 <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) <br /> PRI RP has been named a Primary RP. <br /> Business Name USA PETROLEUM COMPANY <br /> Contact.CHARLES MILLER <br /> Address 30101 AGOURA CT.#200 <br /> AGOURA HILLS,CA 91301-4311 <br /> Phone (213)452-6200 <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 andlor Standards and State and/or Federal Laws. <br /> PRINTED NAME: TITLE: <br /> REPRESENTING: <br /> SIGNATURE: Date <br /> Report#8021 Date 6/152005 <br />