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Date run L 3/23/2010 3:36:29PN SAN JUIN COUNTY ENVIRONMENTAL HEW DEPARTMENT Report 85021 <br /> Run by Page2 <br /> Facility Information as of 3/23/2 <br /> Record Selection Criteria: Facility ID FA0006764 <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 toren. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: 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 e Check Number Recei I W- <br /> RENS: c�11(h Milhi Date /�/ Accountout: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />