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Date run 8/31/2015 3:42:10PN SAN J JIN COUNTY ENVIRONMENTAL HDEPARTMENT Report#5021 <br /> Run W Paget <br /> r Facility Information as of 8/31/2015 <br /> Record Selection Criteria: Facility ID FA0010335 <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 facility <br /> 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 andror Standards and State ancitor <br /> Federal Laws. <br /> �Oe-f <br /> APPLICANT'S SIGNATURE: �D-eDate -/ /d <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / ! <br /> Payment Type Check Nu r Received b <br /> EHD Staff: < �` Date / / Account out: Date / ! <br /> COMMENTS: <br /> Invoice#: <br />