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Date run 10/9/2009 11:02:27AI SAN JOA IN COUNTY ENVIRONMENTAL HEALDEPARTMENT Report#5021 <br />Run by 1273 Paget <br />Facility Information as of 10/9/ <br />Record Selection Criteria: Facility ID FA0009525 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project spec, 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 Ordinace Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE <br />Program Records to be TRANSFERED: ' $20.00 = <br />Water System to be TRANSFERED: ` $372.00 = <br />Payment Type Check Number <br />REHS: Date <br />COMMENTS: <br />\\eh-env\envision\reports\5021. rpt <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Receiv <br />Account out: Date <br />