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'7 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 6/15/2005 <br /> LOP SITE FILE INFORMATIONJS <br /> cal �ency�..Tse„On1X ; <br /> Case# 5063132. ' <br /> Site Name SHELL SERVICE STATION tstne 1r RO 48 <br /> Location 1071 N MAIN $ tccr ID' 04 'P ' <br /> MANTECA,CA 95336 aclllR�CtS Cl AOfO I4 � <br /> Phone 209-823-5265 Cut nt Stri a tress REF L ,� <br /> ji <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 /> li <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 SHELL OIL PRODUCTS US <br /> Contact DENIS L BROWN <br /> Address 20945 S WILMINGTON AVE <br /> CARSON,CA 90810-1039 <br /> Phone <br /> A � oaa�s4��3`, <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 <br /> Report#8021 Date 6/15/2005 <br />