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gate wn, `7/21/2010 10:46:38AI SAN JC . 'JUIN COUNTY ENVIRONMENTAL HEAT qrH DEPARTMENT Report #5021 <br />Run by g <br />- Facility Information as of 7/21/21, , J Pa e2 <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 />Date / <br />Program Records to be TRANSFERED: ' $20.00 = Amount Paid Date <br />Water System to be TRANSFERED: ' $372.00 = Amount Paid Date <br />Payment T pe Check Number Recei Tr <br />REHS: 17.2► ✓ice . Date ` / /�_ Account out: Date <br />COMMENTS: <br />\\eh-env\envision\reports\5021. rpt <br />