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Date <br /> Run byn 8/14/2013 3:42:04Pk SAN J`�ZUIN COUNTY ENVIRONMENTAL HE/ 'H DEPARTMENT Report#5021 <br /> Facility Information as of 8/14/2013 Pagel <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 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 J �� _ <br /> Care of /�/(j>•('S W�/O/J1 (`�py�,�pn�0 �� <br /> FACILITY FILE INFORMATION a ' • bow�S/kY.0 3'* <br /> Facility lD/CERS ID FA0009802 10,182,921 nInGa _ <br /> Facility Name INJECTION MOLDING CORPORATION l�l*J Y) 'V _ <br /> Location 922 INDUSTRIAL WAY STE K �/�/����````���� <br /> LODI, 95240 <br /> Phone 209-333-7406 x0 KIWI k _ <br /> Mailing Address 10824 OLSON DR STE C �(�0 _ ctus—p <br /> RANCHO CORDOVA, CA 95670-5651 I`j <br /> 1 <br /> Care of _ <br /> Location Code 02 - LODI ?11A — <br /> BOS District 004 -VOGEL. KEN _ <br /> APN 04915011 <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 INJECTION MOLDING CORPORATION (Circle One) <br /> Account Balance as of 8/14/2013: $571.00 <br /> (Circle One) <br /> Transfer to Active/Inadve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO520190 EE0008709-JAMIE DE LA ROSA Active Y N A © D <br /> 2220-SM HW GEN<5 TONS/YR PRO522198 EE0001422-ARTS CACAPIT Active Y N A © D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512090 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509802 EEOOOOOOO-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 specific,PHS/EHO hourly charges associated with this facility <br /> 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 Ordinance Codes andor Standards and State andor <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 Received by <br /> RENS: Date / / Accou tout: Date <br /> COMMENT9r� ' n N'/4 <br />