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Dale run 12/30/2009 12:00:14F SAN 30AOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5ort <br /> Run by k Page2 <br /> Facility Information as of 12/30/21( <br /> Record Selection Criteria: Facility ID FA0000903 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this <br /> facility or activity Y411 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 Ordinate Codes and/or Standards and ; <br /> Slate and/or Federal Laws. <br /> 4 . <br /> APPLICANT'S SIGNATURE: hate / ! <br /> Program Records to be TRANSFERED: - '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date 1 I <br /> Payment T Check umber Receiv b 1 <br /> REHS: Date / I !. ! /U . Account out: Date I I f <br /> COMMENTS' <br /> '�S�rQ^/- of c <br /> Tit/d/ ZILI <br /> i <br /> ' J <br /> . I <br /> Y � <br /> I <br /> . I <br /> - i <br /> I <br /> 4 <br /> I <br /> I <br /> i <br /> # lleh-envlenvisionlreports15021,rpt <br />