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RECEIVED <br />SAN J. .UIN COUNTY ENVIRONMENTAL HEALTH I ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM OCT 6 9 2017 <br />"MFR"- GREEN FORM <br />DATE Sentember 25.2017 <br />.1,11-11irtL ri <br />SHArnfatrr4gErgyii),PE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY' ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />TervInder K. Banes, Trustee of the TarvInder K. Banes Revocable Living Trust Dated October 22, 2007 PHONE 949-800-8341 <br />FIRST MI LAST <br />BUSINESS NAME E-MAIL ADDRESS <br />OWNER HOME ADDRESS 8111 TURNBERRY COURT ATTENTION: ORCARE OF (01,170NAL) <br />CITY DUBLIN CA 94688 STATE CA ZIP 94688 <br />OWNER MAILING ADDRESS SAME AS ABOVE <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION <br /> <br />0 INDIVIDUAL 0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> g OTHER <br />IN ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />EHD LOCAL VOLUNTARY RWQCB LEAD— RWQCB LEAD— <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />IN DTSC LEAD FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No M <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES ft( No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME VACANT APN: <br />SITE ADDRESS! PROJECT LOCATION 520 NORTH EL DORADO ST. BUSINESS PHONE <br />CRY STOCKTON SAE ZIP 96202 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE I I Kerl Kei2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS SAME AS ABOVE <br />MAIUNG ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME 620 EL DORADO LLC <br /> <br />ATTENTION: ORCARE OF (OPTIONAL) <br />MAILING ADDRESS 2700 PACIFIC COAST HWY, 2ND FLOOR <br /> PHONE 949-800-8341 <br />CRY TORRANCE <br /> STATE CA ZIP 90505 <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNER0 <br /> <br />FACILITY/BUSINESS:I <br /> <br />THIRD PARTY BILLINGX <br /> <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or <br />Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br />this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information <br />provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br />JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br />Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br />release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) ALEX OSINSKI <br /> <br />SIGNATURE <br /> <br />TITLE PROJECT MANAGER <br /> <br />TAx ID # <br /> <br />FA S: i--3-AotaLos-1 OWNER ID #D41}602.253-3(9 ACCOUNT #: 74RxiK2 I ( ASSIGNED TO: <br />PR X: _19/2.Ds 1+221 *ir ACCOUNTING COMPLETED BY: 7/ 9 L DATE: / <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUES INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 f t, , ,, , - , › k /,/17 S -X2-72z.,)e <br />Site Mitigation MFR 29- XXX 8-1-2017