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San Joaquin County Environmental Health Department DATE 2/10/2012 MASTER FILE RECORD INFORMATION "MFR" 411 GREENFORM SITE MITIGATION & LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV S�C,y SZ OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION.• CHEcKIF OWNER CURRENTLYoNFILEW/TH EHD PROPERTY OWNER NAME Stephen J Donell (310) 207-8481 First Ml Last PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS 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 r] SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNT ID PR#IRO?{ ASSIGNED EIi MPLOYEELEAD AGENCY:EHD_Z RWQCB_DTSC_EPA_ FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO El IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES El NO ❑ BUSINESsIFACILITY/SITENAME Industrial Drive Receivership Estate SITE ADDRESS 248 Industrial Dive SUITE# BUSINESS PHONE CITY Stockton STATE zip CA 95206 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 Mailing Address WD/FFERENTfrom Facility A ddress Attention:orCare Of(optional) 12121 Wilshire Boulevard, #1120 Mr. Steve Donell Mailing Address City STATE ZIP Los Angeles CA90025 SIC CODE APN# 7 COMMENT: 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 CITY STATE zip ACc_oLNLADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLHDGME:NI': 1,the undersigned Applicant,certify that 1 atn the Oamer,(Operator,or Authorized Agent of this Business,and I acknowledge that all PERUIt'FEE.t', PENALnEs,ENFoRcE.l1EA'r CHARGF-v and/or 11o1'R1.YC'HA1oGES associated with this operation will be billed to me at the address identified above as the A((Ot'A7 ADDRESS for this site. 1 also certifv 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 the property located at the above facility/site address,1 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. moi" APPLICANT NAME(PLEASE PRINT) Stephen J. Donell SIGNATURE , TITLE Receiver TAxID# 806189396 Approved By I Date Accounting office Processing Completed By Date SITE MITIGATION AMOUNT ')PAID DATE OF PAYMENT tP—AYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEES l��— � /� ��-4? ct.L`CT" -Z JV