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Date run X4/1/2013 12:00:02PM SAN JOO[IIN CQUT1TUNVIRONMENTAL HEADEPARTMENT Report#5021 <br />Run by Paget <br />Facility information as of 4/1/2013 <br />Criteria: Facility 10 FA0006943 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, endfor project specific, PHS/EHD hourly charges associated with this facility <br />or activity will be billed to the party identiflad as the OWNER on this form I also ce 11y that all operation will be pe ormed in accordance with all applicable Ordinance Codes anclor Standards and Slate andfor <br />Federal Law& <br />APPLICANTS SIGNATURE: Date -/ /0 <br />Program Records to be TRANSFERS : ' $25.00 = Amount Paid 15A29 • Date 14 <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type ✓ Check Number gB Rec W y <br />REHS: Date /�/ Account out: Date <br />COMMENTS: e (/G/ oz ` <br />PAYMENT <br />RECEIVED <br />APR 0 12013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />Ckpoatr, <br />I �t D '�ZA a- <br />S(ZODLL-1Y-L <br />