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Dale run 10/2/2012 8:09:09AK SAN JUIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report 95021 <br /> Paget <br /> Run by Facility Information as of 10/2/20 <br /> Record Selection Criteria: Facility ID FA0006943 <br /> LING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHS/EHD hourly charges asmciated with this facility <br /> 46 divity,will be billed to the party identified as the OWNER on this form I also citify that all operations will be performed in accordance with ell applicable Ordinance Codes andor Standards and Stele andw <br /> oral 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 <br /> Payment Type Check Number Re by <br /> REHS: Date_/_/_ Account out: Date�_/ILL <br /> COMMENTS: <br /> • <br /> • <br />