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12/27/2011 14:04 2094640138 ENVIKUNMENIAL HEALIn rrau¢ Uarw <br /> "nle. 1223/2011 1:36:11P SAN�QUIN COUNTY ENVIRONMENTAL HEAl�DEPARTMENT <br /> Rurwy Kwon✓aoZt <br /> Facility Information as of 12/23(2011 PSQ02 <br /> Rnoord ttalM Caere' FanlNy ID FA0006195 <br /> BILLING and COWLIANCG ACIW011&EDGEMENT: I,The tmdyaigned ewner,opermor or agnnt a m".natAawladle that W eer,envy ePt <br /> m61v or me Nty wW ea billed to the Parlor aantaad as the OWNER on INe form. I alae tap ,"WI � aPacald.PNNENO Iqurty c112!{Jer aRSeolblea calla tl`s <br /> Slay aMry Fadenllaws. IfY opy90ane can be pMermad <br /> '"""aamo*whh all hPPllmNe Or(aaoe Code;am/or Slanda,on and <br /> APPLICANTS SIGNATURE: <br /> Program Records to be TRANSFERM '$23.00= Amoum Pop Date _/—/y <br /> Date^/�! <br /> Water System ED be TRANSFERNSFERED: Amount Paid Date <br /> z!/ <br /> Payment Typo . Check Number L <br /> RENS: ISL N'7'L, Date / R <br /> _/�_ Account out am y Data <br /> COMMENTS: <br /> REDE�►�D <br /> DEC 2 7 2011 <br /> SAlVj�CE0FE14Q N�OUWY <br /> 11eh-envlennslonlreports1S021.rpt <br />