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,r;ate-un` 6/18/2010 3:21:32PN SAN JC WIN COUNTY ENVIRONMENTAL HEA" ''H DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 611812` Page2 <br /> Record Selection Criteria: Facility ID FA0010218 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEH❑hourly charges associated with this <br /> facility 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 Ordinate Codes andlor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: `$372.00= Amount Paid Date / ! <br /> Payment Type Check Number. Recei <br /> RENS: l`I2';- Date ! _/� Account out: Date 1 ! <br /> COMMENTS: <br /> A <br /> lleh-envlenvisionlreports15021.rpt. <br />