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j SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> LOP SITE FILE INFORMATIONJ5i2('/ <br /> {u <br /> Case# 1882 <br /> Iief�tediat O iersight 1 <br /> Site Name AMERICAN MOULDING&MILLWORK ���� ROD000025 ? ,may U <br /> Location 2801 WEST LANE LN SlteRee nl.i� DOpODd2S �� ° <br /> STOCKTON,CA 95208 - - Fecltlh'Recard ID'�I'tYQI1Q4032k, ,i� <br /> g, <br /> Phone 209-946-5880 <br /> j 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 /> I. Business Name AMERICAN FOREST PRODUCTS CO LP 's <br /> Contact WILLIAM BERGWALL `a <br /> Address 2977 YGNACIO VALLEY RD#241 <br /> WALNUT CREEK;CA 94598 <br /> Phone <br /> A2002 $ -P30 <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 /> r <br /> PRINTED NAME: TITLE: ! <br /> REPRESENTING: - - <br /> SIGNATURE: Date <br /> Report#8021 Date 6/15/2005 <br />