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SAN JOAQI COUNTY ENVIRONMENTAL HEALTH PARTM T r �' <br /> LOCAL OVERSIGHT PROGRAM <br /> Responsible Party Information as of 2/18/2009 MAR 0 <br /> _. VIRONPJ1tNI ;rte, . H <br /> PERMIT,/SERVICES <br /> LOP SITE FILE INFORMATION <br /> Local Agency Use Only <br /> Case# 0001322 ! <br /> Site Name LOW PRICE AUTO GLASS Remedial Oversight R00001322 <br /> Record ID <br /> Location 3978 S HWY 99 RTE Site Record ID SDO001322 # <br /> STOCKTON, CA 95205 <br /> Phone 209-948-4975 , <br /> APN 17917103 <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 changes/corrections in RED ink or encil. <br /> RESPONSIBLE PARTY INFORMATION RP INFORMATION CHANGE(date) <br /> PRI-RP has been named a Primary RP. <br /> Business Name LOW PRICE AUTO GLASS <br /> Contact SANDRA YACOUB <br /> Address 3978 S.HWY 99 E FRONTAGE ROAD <br /> STOCKTON,CA 95205 <br /> Phone (209)948-4975 <br /> PRI-RP has been named a Primary RP. <br /> Business Name CHEVRON ENVIRONMENTAL MGMT CO <br /> Contact STEPHANIE FURGAL -- <br /> Address V l y- <br /> SAN RAMON,CA 94583 � 5 / ,q <br /> Phone (9�Sjg�TT4bb /b� cr�- 9:?;� ` ZI-6`4 1 <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 RESPONSIPI-E 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: f�V`�(� t e— l/LM a'I TITLE: ?�1-e� � e� <br /> ►►--� <br /> REPRESENTING: i'Avlov\ <br /> SIGNATURE: Date _�/��/ 9 <br /> Report#8021 Date 2/18/2009 <br />