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Date run 9/24/2014 8:07:57AR SAN JO JIN COUNTY ENVIRONMENTAL HEATI DEPARTMENT Repel#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 9/24/2014 <br /> Record Selection Criteria. Facility ID FA0010213 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008213 Case Number: H07355 New Owner ID <br /> Owner Name HARRISON, MITCH <br /> Owner DBA VALLEYDRILLING <br /> Owner Address <br /> ACAMPO, CA 95220 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-369-2779 <br /> Mailing Address PO BOX 42 <br /> GALT, CA 95632 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010213 10183323 <br /> Facility Name VALLEY DRILLING <br /> Location 25751 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Phone 209-369-2779 x <br /> Mailing Address PO BOX 42 <br /> GALT, CA 95632 <br /> Care of MITCH HARRISON <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 00514127 Eli <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017213 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name HARRISON, MITCH (Clras0.) <br /> Account Balance as of 9/24/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> PrograMElement and Descripbon Record ID Employee ID and Name status New Omer? Delete <br /> 1920-HMBP-Common Materials PR0520151 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512501 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510213 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532988 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.PHSIEHD hourly charges assacated with this facility <br /> or activity will be billed to the party identfied as the OWNER on this form. I also certify that all operations will ba performed in accordance with all applicable Ordinance Codes arM'or Standards and State ands <br /> Federal Laws <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date /_/ <br /> Water System to be TRANSFERED: Amount Paid Date I / <br /> Paymen y Check NumberRecei y <br /> REHS: �1 Y1/a A Date lel Account out Date <br /> CO9trMMENTS: phylliS H�-rrislm lJUurv1.r c�ddre�g is 2.S7o7 I (Q� . <br />