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"""""" Y/J/Lv Iv V.VL.V✓� ��� ,7H1\ JVH�U11\ �.V V1\ 1 1 L' 1\ � 11\Vl\1�l lilt lAL 11liAL 111 Llil AL\11�11L1� 1 <br />Run by 1273 Paget <br />Facility Information as of 4/9/2( <br />Record Selection Criteria: Facility ID FA0003793 <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 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 />I <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Receiv <br />Account out: Date <br />