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Date run 8/20/2008 11:12:40AI SAN JUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 8/20/2 Paget <br /> Record Selection Criteria: Facility ID FA0009802 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007802 Case Number: H05461 New Owner ID <br /> Owner Name INJECTION MOLDING CORPORATION <br /> Owner DBA INJECTION MOLDING CORP <br /> Owner Address 2210 SUNDALE DR <br /> RANCHO CORDOVA, CA 95670 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-7406 <br /> Mailing Address 2210 SUNDALE DR All <br /> RANCHO CORDOVA, CA 95670 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009802 <br /> Facility Name INJECTION MOLDING CORPORATION <br /> Location 922 INDUSTRIAL WAY STE G <br /> LODI, CA 95240 <br /> Phone 209-333-7406 x0 <br /> Mailing Address 922 INDUSTRIAL WAY STE G <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04915011 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KARAN HATZENBELER &TIM TACHIBANA <br /> Title CORP OFFICERS <br /> Day Phone 209-333-7406 <br /> Night Phone 916-853-1334 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016802 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name INJECTION MOLDING CORPORATION (Circle One) <br /> Account Balance as of 8/20/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/inacwe <br /> Program/Element and Description Record 10 Employee ID and Name Status New Owner? Delete <br /> 222 -USED OIL ONLY-<5 TONS/YR PR0522198 EE0001422-ARIS CACAPIT Active Y N A D <br /> 224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512090 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0520190 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0509802 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly Charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also cerfify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> Stale andfor Federal Laws. <br /> APPLICANT' SIG URE Date <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Dale <br /> Payment Type Check Number Received by <br /> REHS .mac Date / / Account out: _�� Date_ /_!r�/ b SS <br /> COMMENTS: <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />