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San Joaquin County Environmental Health Department DATE 8=17--f22-- MASTER FILE RECORD INFORMATION"MFRLL— GREEN FORM SITE MITIGATION& LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# �� UNIT IV OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHECKIF OWNER CURRENTLYoNF1LE WITH EHD PROPERTY OWNER NAME Stephen J Donell 310) 207-8481 First MI 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 Anaeles State CA ZIP 90025 CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY I D# INv# ACCOUNT ID P IRO# ASSIGNED EMPLOYEE LEAD AGENcY:EHD_Z_RWQCB_OTSC_EPA_ 2LL Sl,-, 3$'D-If I 534908 FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMArlow Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ® No ❑ BUSINESS/FACILITY/SITE NAME Industrial Drive Receivership Estate SITE ADDRESS 248 Industrial Dive SUITE# BUSINESS PHONE CITY Stockton zip Stockton CA 95206 BOARD OF SUPERVISOR DISTRICT / LOCATION CODE / KEY1 KEY2 Mailing Address WDIFFERENTfrom Facility Address Attention:orCare Of(optional) 12121 Wilshire Boulevard, #1120 Mr. Steve Donell Mailing Address City STATE ZIP 90025 Los Angeles CA SIC CODE APN# COMMENT: /r -Zv 71 THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME Attention:orCare Of (optional) Mailing Address PHONE STATE ZIP CITY ACCOUNTAODRF.S.S for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Awhorized Agent of this Business,and I acknowledge that all PERAHT FEEL, PENALTIES,ENFORCEAfENI'CHARCES and/or HOURLYCHARCEV associated with this operation will be billed to me at the address identified above as the AC'C'OUNfADDRES'3 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 Ind/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the 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 Date /7 It 2-- SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEE:$ 1 JCJ