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Date run - 8/24/2011 11:28:35AI SAN JO TJIN COUNTY ENVIRONMENTAL.HEAL—vi DEPARTMENT Report#5021 <br /> Run byPaget <br /> Facility Information as of 8/24/20 <br /> Record Selecfion Cinema: Pacety ID FA0009750 <br /> BILLING arW COMPLIANCE ACKNOWLEDGEMENT: I,the uodemigned owner,operator or agent of same,ackrgwledge that all site,aMfor project specific.PHS/EHD hourly charges assocated with"is <br /> facility,or activity,volt be plied to If*pard identified as Ina OWNER on this form. I also cemiry that all operabons will be performed in accordance with all applicable Ordinace Godes arWfor StandarGs and <br /> Stale and/or 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 /> Payment Type eck Number Rece y <br /> RENS: Date l4LI1L. Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />