Laserfiche WebLink
Date run 11/13/2015 10:49:59/ SAN JUIN COUNTY ENVMONMENTAL HEt�H DEPARTMENT Report#5021 <br /> Run by a Paget <br /> Facility Information as of 11/13/2 15 <br /> Record Selection Criteria: Facility ID FA0010134 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHS/EHD 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 and'or 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_/ I <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date / / <br /> COMMENTS: <br /> Invoice#: <br />