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rDate run 3/2/2011 10:02:10AM SAN JO -1UIN COUNTY ENVIRONMENTAL HEAD —1 DEPARTMENT Report »5021 <br />Run'Y <br />Facility Information as of 3/2I20`r"" Paget <br />Selection Catena: Facility ID <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 pad identified as the OWNER on this form. I also certify that all operations will be performed in accordance Mh all applicable Ordinate Codes andlor Standards and <br />Stale and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: _ <br />Date <br />$25.00 = Amount Paid Date _ <br />Amount Paid Date <br />Payment Type Check Number <br />REHS: Dated/_/�_ Account out: <br />COMMENTS: <br />\\eh-env\envision\reports\5021. rpt <br />Date <br />