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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE September 300 2016 SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IP OWNER IS CURRENTLY ON PILE WITH EHD <br />PROPERTY TAR <br />OWNER NAME <br />IINDER K. I3AINS, TRUSTEE OF THE TARVINDER R. BMNS R EVOCABLE LIVING TRUST DATED OCTOBER 22, _cirwe 9498008341 <br />FIRST MI LAST <br />BUSINESS NAME E-MAIL ADDRESS <br />OWNER HOME ADDRESS 6111 Turnberry Ct ATTENTION: °HOARE OF (OPTIONAL) <br />CITY Dublin, CA 94568 STATE CA ZIP 94568 <br />OWNER MAILING ADDRESS As Above <br />lamito ADDRESS CITY STATE ZIP <br />0 CORPORATION <br /> 0 INDIVIDUAL <br /> <br />0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> N OTHER <br />% ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />EHD LOCAL VOLUNTARY RWQCB LEAD— RWQCB LEAD — E DTSC LEAD <br />2959 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />FED EPA LEAD <br />2954 <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES M No 0 <br />YES 0 No 0 <br />BUSINE138/FACILITY/SITE/PROJECT Noun Vacant APN: <br />SITE /known / PRoJecrLocKnom 520 North El Dorado St BUSINESS PHONE <br />Coy Stockton, California STATE ZIP 95202 <br />BOARD OF SUPERVISOR DISTRICT I 1 LOCATION CODE 1 _ Kerl I i Ket2 <br />MAIUNG ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS As above <br />MAILING ADDRESS CITY STATE ZIP <br />SIC Cone COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />ATTENTION: OR CARE OF (OPTIONAL) BUSINESS NAME Inner Circle Investments, Inc. <br />MAIUNG ADDRESS 610 Newport Center Drive PHONE 949 800 8341 <br />CITY STATE Newport Beach CA ZIP 92660 <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> OWNERO <br />FAcILITY/BUSINESSEI <br /> <br />THIRD PARTY BILLINGM <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />with 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 authoriz <br />release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRO <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or m epi sentative. <br />APPLICANT NAME (PLEASE Paint) Gavin Read <br />SIGNATURE <br />Mil Manger Tax ID# <br />FA #: :73,-A <br />1 741) 2- 1 og-7 OWNER ID #:0000 17 3.5_„:7 ACCOUNT #: Aizzlo37 777 ASSIGNED TO: <br />PR #: F g- 053 c,. 7/0 ACCOUNTING COMPLETED BY: <br />(21- <br />DATE: /04 <br />9-3-2015 <br />Site Mitigation MFR 29-