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Date run 6/15/2010 9:50:23Af $AODAQUIUNTY ENVH2ONMENTAL0LTH DORTMENT <br />Report#5021 <br />Run b: >• Page2 <br />Facility Information as of 6/15/2010 <br />Record Selection Criteria: Facility ID FA0009860 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD 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 Ordinance Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANTS SIGNATURE: <br />Program Records to be TRANSFERED: " $20.00 = Amount Paid <br />Date <br />Date <br />Water System to be TRANSFERED: ' $372.00 = Amount Paid Date <br />Payment TLv1ne �heck Piumber Received by <br />REHS:r�Cl1 SCS eZC'6 (�.6LL Date /10 Account out: Date_—& <br />COMMENTS: <br />'::LnatAi4cl; , P.E. 47 HD <br />\\etre nv\envision\reports\5021. rpt <br />