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Date run 8/4/2015 10:35:18AM SAN JO 'JIN COUNTY ENVIRONMENTAL HEA' ' DEPARTMENT Report#5021 <br />Run by Paget <br />Facility Information as of 8/4/2015 <br />Record Selection Criteria: Facility ID FA0009628 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andor 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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff:���, <br />COMMENTS: <br />* $25.00 = Amount Paid _ <br />Amount Paid <br />Date <br />_ Date <br />_ Date <br />Received by <br />Date IS—Account out: JAt) Date / 47 !is <br />Invoice #: <br />