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: . SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as`of 6/15/2005 <br /> C <br /> LOP SITE FILE INFORMATION ; <br /> Case# 1125 Lc31 At1G lOrtl <br /> _ t it,'Ci Cu4t It[)t)ppfi07Q ': <br /> Site Name BEACON#3-641 <br /> ��t=d iii. �• ' <br /> Location 1210 E HAMMER LN r I741w l ` <br /> STOCKTON,CA 95210 �tl lId330 <br /> Phone 209-477-3111 <br /> V <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,'l <br /> sizn and return this form. <br /> Make changes/corrections in RED ink or pencil. <br /> v RESPONSIBLE PARTY INFORMATION RP INFORMATION CHANGE(date) <br /> PRI-RP has been named a Primary RP. Y g <br /> Business Name ULTRAMAR INC 1 <br /> Contact ROB FISHBURN ±_ <br /> Address 685 W THIRD STREET <br /> HANFORD,CA 93230 !! <br /> Phone <br /> ki <br /> - 1 <br /> 4 <br /> I <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 Ord in ace Codes and/or Standards and State and/or Federal Laws:' <br /> PRINTED NAME: TITLE: <br /> REPRESENTING: <br /> SIGNATURE: Date <br /> Report#8021 Date 6115/2005 <br /> 1 <br /> I <br /> f <br />