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San Joaquin County Environmental Health Department DATE 2/10/2012 MASTER FILE RECORD INFORMATION"MFR" GREENFORM /�'R#'i"SITE MITIGATION & LOP SHADEDAREASFoREHDuSEONLY OWNER[DO CASE# SQOOC'yZp, UNIT IV OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMAT/Ow CHECK/FI OWNER CURRENTLYONF/LEW/TN EHD PROPERTY OWNER NAME Stephen J Donell 310) 207-8481 First MI Last PHONE NUMBER BUSINESS NAME E-MAILADDRESs Industrial Drive Receivership Estate steve.donell@fedreceiver.com Owner Home Address City STATE zip Owner Mailing Address 12121 Wilshire Boulevard, #1120 Mailing Address CRY Los Ana,-les State CA Zip 90025 CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER SIT!MITIGATION_ENVIRONMENTAL AssE wcw_VOLUNTARY CLEANUP_WATER QUAuTY_HW PIPELINE INVnT1IGAT10N_LOP_ FACILITYID# INV# ACCOUNTID PR# RO# ASSIGNED CMPLOYEE LEAD AGENCY:EHD_ —RWQCB_DTSC_EPA'_ 2-t o o to FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.' Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 91 Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES El No ❑ BUSINESS/FACfiJTY1SITENAME 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 KDJFFERENTframFac1111yAddress Attention:orCare Of(optbnal) 12121 Wilshire Boulevard, #1120 Mr. Steve Donell Mailing Address City STATE ZIP Los Angeles CA 90025 SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identffied above. BUSINESS NAME Attention:orCare Of(optlonal) Mailing Address PHONE CITY STATE LP ACCOUNTADDRES.4 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BI LLI N6 AND CONIPLIA NCE ACKNOWLEDGNI ENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENAL 71Fs,ErvFoRCEatEA7'CHARcei and/or HoORLr CHARLES associated with this operation will be billed to me at the address identified above as the ACCotkw ADOREl'S 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 STA'T'E and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilitAite address,I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENN'IRON:MENTAL HEALTH DEPARTN as it is ailable d at the some time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Stephen J. Donell SIGNATURE TITLE Receiver TAxID# 806189396 Approved By Date Accounting Office Processing Completed By �j� Date 3 L n ATION AMOUNT PAID D TE OF PAYMENT P1AY/MENTTYPE4,R.ECEIPT# CHECK# RECEIVEDBYWORK PLAN PE �! V 1�7 N