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San Joaquin County Environmental Health Department 5 DATE -22_I-� MASTER FILE RECORD INFORMATION"MFR" )LC- GREEN FORM L 7 SITE MITIGATION&LOP SHADED AREAS FOREHD USE ONLY OWNER ID# CASE#��a�7ZZg UNIT IV OWNER FILE:COMPLETE THEFOLLOW/NGPROPERTYOWNERINFORMAT/ON.' CHEcKiFOWNER cuRRENTLYoNF/LEwITHEHD PROPERTY OWNER NAME Stephen J Donell 310) 207-8481 First Ml Last PHONE NUMBER E-MAIL ADDRESS BUSINESS NAME Industrial Drive Receivership Estate steve.donell@fedreceiver.com Owner Home Address City STATE ZIP Owner Mailing Address 12121 Wilshire Boulevard, #1120 Mailing Address City Los Anoeles State CA ZIP 90025 CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER IJ SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INv# AccouNrlD P IRO# ASSIGNED EMPLOYE77-777 AGEN _DTSC_EPA_ 2LtS S3c�gv8 �oMlvv� FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.' Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Fil IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ® No ❑ BUSINESS/FACILITY/SITE NAME Industrial Drive Receivership Estate SSUITE# BUSINESS PHONE SITE ADDRESS 248 Industrial Dive STATE ZIP CITY Stockton CA 95206 BOARD OF SUPERVISOR DISTRICT / LOCATION CODE / KEY1 KEY2 Mailing Address WDIFFERENTfrom Faci/ityAddress Attention:orCare Of(option/) 12121 Wilshire Boulevard, 41120 Mr. Steve Donell Mailing Address Ctty STATE Zip 90025 Los Angeles y ^ CA SIC CODE APN#/ 77-2-7 y L 1 6 OMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifiedabove. BUSINESS NAME Attention:orCare Of(opdonal) Mailing Address PHONE STATE ZIP CITY AccouNrADqBFss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Oliver,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAtrr FEES, PENALTIES,ENFORCEAfENI'CHARCES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AcrouNTADORE.SS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of file property located at the above facility/site address,I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. •_�_"'` APPLICANT NAME(PLEASE PRINT) Stephen J. Donell SIGNATURE TITLE Receiver TAX ID# 806189396 Approved By Date Accounting Office Processing Completed By 3 SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYt.:ENT T YPE RECEIPT# CHECK# RECEIVED BY WORK [PLAN PE FEE: