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Date run 6/5/2014 10:55:22AIV SAN J( TJIN COUNTY ENVIRONMENTAL HEE T DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 6/5/2014 <br /> Record Selection Criteria: Facility ID FA0009092 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ancVor 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 andror Standards and Slate andlor <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 <br /> Paymenta rt-- __Check Number Recei <br /> REHS: �V w C U�-� Date & IT Account out: "—Date le / /z� <br /> COMMENTS: <br />