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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'T'MENT <br /> S;E <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> LOP SITE FILE INFORMATION <br /> .I 1e <br /> Case# 1882 i i, sscl' ertc � n <br /> Site Name AMERICAN MOULDING&MILLWORK ; :� tt3a} Eergha ' � <br /> n; �t�� <br /> Location 2801 WEST LANE LNtte�eca�td <br /> STOCKTON,CA 95208 <br /> Phone 209-946-5880 <br /> The following information is currently on file with this:Department. The Primary Responsible Party <br /> 14 <br /> identified below will be responsible for payment of invoices for direct oversight charges associated with this <br /> g;l l <br /> site. If this billing information is riot accurate, please:make necessary changes in the space provided,date, <br /> sign and return this form. 0 <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 .: <br /> . AMERICAN FOREST PRODUCTS CO LP i;° <br /> Contact WILLIAM BERGWALL <br /> Address 2977 YGNACIO VALLEY RD#241 <br /> WALNUT CREEK,CA 94598 <br /> Phone <br /> } <br /> it F <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 Ordinate Codes and/or Standards and State and/or Federal Laws. <br /> PRINTED NAME: TITLE: <br /> REPRESENTING: <br /> F <br /> SIGNATURE: Date 1 l <br /> 'r <br /> Report#8021 Date 6/15/2005 <br />