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Date run 11/18/2015 3:01:25F SAN JOIN COUNTY ENVIRONMENTAL HEAV <br /> I DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 11/18/2 <br /> Record Selection Criteria: Facility ID FA0010456 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD 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 andfor Standards and State andlor <br /> Federal Laws <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date /_/ <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Ch Ck Number Received by <br /> EHD Sta Date 1Ll /� Account out: 4! Date <br /> COMMENTS: <br /> Invoice#: <br />