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Date run 2120/2013 11:27:07A1 SAN JC�COUNTY ENVIRONMENTAL HEA_ ' DEPARTMENT Report#5021 <br /> Run by V. Pagel <br /> Facility Information as of 2/20/203 <br /> Record Selection Criteria: Facility ID FA0009802 <br /> Make changes/corrections in RED Ink. <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 1,0 zzcz 11 Z9'L..;'d7 r Q TE <br /> RANCHO CORDOVA, CA 95670c — ! <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-7406 <br /> Mailing Address 2210 SUNDALE DR 1/g7,,Q A L. )2 -�C'TZ: <br /> RANCHO CORDOVA, CA 95670-5-&51 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009802 <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 922 INDUSTRIAL WAY STE K 19SAL6 69L <br /> LODI, CA 95240 O LIB D'1L� S�v77 lo�� <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 <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016802 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name INJECTION MOLDING CORPORATION (cildeOne) <br /> Account Balance as of 2/20/2013: $348.00 <br /> (Circle One) <br /> Transfer to Activennactve <br /> ProgreMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 9192 HMBP-Common Materials PR0520190 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 0-SM HW GEN<5 TONSNR PRO522198 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO512090 EEO000000-HAZ MAT SJC GIES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PRO509802 EEO000000-HAZ MAT SJC GIES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCKPRO532749 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party idenlned as the OWNER on this form I also certify that all operations will be performed In accordance with all applicable Ordinance Codes anclor Standards and State and'or <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 Receive _ <br /> REHS: Dyaart(e��,��[r // / Acccounnttt ouuutt:://�J Date <br /> COMMENTS: <br />