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Date run 1/15/2004 4:05:06PN SAN JO1W COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by � SII Pagel <br /> Facility Information as Of 1/15/2004 <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 <br /> Owner ID OW0007802 Case Number: H05461 New Owner ID <br /> Owner Name MARK BRYAN <br /> Owner DBA MOLDCRAFTERS <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-7406 <br /> Mailing Address 922 INDUSTRIAL WAY <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009802 <br /> Facility Name, MOLDCRAFTERS <br /> Location 922 INDUSTRIAL WAY <br /> LODI, CA 95240 <br /> Phone 209-333-7406 <br /> Mailing Address 922 INDUSTRIAL WAY <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02- LODI APN:4915011 <br /> BOS District 004-SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016802 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MARK BRYAN (Circle one) <br /> Account Balance as of 1/15/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record I Employee to and Name Status New Omer? Delete <br /> 2221 -USED OIL ONLY-<5 TONS/YR PRO522198 EE0008389-DENNIS CATANYAG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512090 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520190 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0509802 EE0000000-HAZ MAT SJC OES 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 speck,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws, <br /> APPLICANT'S SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: `$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: •$155.00= Amount Paid Date r <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />