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400 .,. <br /> 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# 1125 Vie Only <br /> s Iieracfr�t C�vei�Fit <br /> Site Name BEACON #3-641 <br /> Location 1210 E HAMMER LN pip..ReK T 1I } I?"i1 <br /> STOCKTON,CA 95210 I FactltyFecor19113 t�fQ373€� <br /> Phone9_ <br /> _0 477-31 I 1 CuktttPd ,ST�T1C}1� <br /> Af'I {l4(IIfI*12 <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 changeslcorrections 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 ULTRAMAR INC <br /> Contact ROB FISHBURN <br /> Address 685 W THIRD STREET <br /> HANFORD,CA 93230 <br /> Phone <br /> r <br /> 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 Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> PRINTED NAME TITLE: <br /> REPRESENTING: <br /> SIGNATURE Date 1 ! <br /> Report#8021 Date 611 s1200� <br />