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Date run 11/19/2009 9:04:13A SAN JOOIN COUNTY ENVIRONMENTAL HEAP Tu DEPARTMENT Report#5021 <br /> •Run by Facility Information as of 11/19/x___ Pa9 e2 <br /> Record Selection Criteria: Facility ID FA0007094 <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: 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 Type Check Number Receive <br /> RENS: O ✓'j-A Date��/�/ Account out: ��C Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />