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r� <br /> Date run 9/4/2013 ;83 ;12A <br /> AN J(�` ,VIN COUNTY ENVIRONMENTAL HEA-� DEPARTMENT Report#5021 <br /> Run by \/ Pagel <br /> Facility Information as Of 9/4/2013 <br /> Record Selection Critena: <br /> Make changes/corrections In RED ink. c� <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 10824 OLSON DR STE C <br /> RANCHO CORDOVA, CA 95670-5651 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-7406 <br /> Mailing Address 10824 OLSON DR STE C <br /> RANCHO CORDOVA, CA 95670-5651 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009802 10,182,921 <br /> Facility Name INJECTION MOLDING CORPORATION <br /> Location 922 INDUSTRIAL WAY STE K <br /> LODI, CA 95240 <br /> Phone 209-333-7406 x0 <br /> Mailing Address 10824 OLSON DR STE C <br /> RANCHO CORDOVA, CA 95670-5651 <br /> Care of <br /> Location Code 02 - LODI Ah Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04915011 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <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 INJEto <br /> DINGCORPORAT r QU4 (Circle One) <br /> Account Balance as of 9/4/2013: <br /> (circle one) <br /> "/ % Transfer to Aclivellnaceve <br /> 4"HAZ <br /> Element and Description Record ID Employee Oland Name • Status New Owner? Delete <br /> HMBP-Common Materials PRO520190 EE0008709-JAMIE DE LA ROSA Active Y N A D <br /> SM HW GEN<5 TONS/YR PR0522198 EE0001422-ARIS CACAPIT Active Y N A g D <br /> MAT BUSINESS PLAN AUTHORIZATION PRO512090 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509802 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532749 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project spaclgc,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number _Receiv d y <br /> RENS: Dale / /_ l'�`)_ Account out: Date <br /> COMMENTS: <br /> QI CA�Ll <br />