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Date run 11/8/2010 11:06:33AI SAN X- ZUIN COUNTY ENVIRONMENTAL HEA' "'H DEPARTMENT Report#5021 <br /> Cun by . J Paget <br /> )� Facility Information as of 11/8/2b'1'0 <br /> Record Selectbn Criteria. Facility ID FA0004044 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,pa undersigned owner,operator or agent of same,acknowledge that atl site.and/or project specific.PHS/EHD hquly charges associated wah pts <br /> facility,or activity mll be billed to the party identified as to OWNER on Use forth. I also certify flat all operations win be performed in accordance with all applicaba Ordinate Codes ardlor Standards and <br /> State andlor Federal Laws <br /> APPLICANTS SIGNATURE t � Date �/ A� <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid <br /> Payment Type eck Number Received by <br /> REHS: Date 77 / 16' / V Account out: W—&,- Date <br /> COMMENTS: <br /> \\eh- v\envision\reports\5021.rpt <br />