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Date run 12/15/2008 8:56:41A) SAN JO UIN COUNTY ENVIRONMENTAL,HEA .�DEPARTMENT <br /> Run by '�._.:�'' Report;K%21 <br /> Facility Information as of 12/15/208 Paget <br /> Record Selection Criteria: Facility ID FA0006832 j <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,admoWedge that all site,and/or r ect i <br /> facility a activity will be billed to the party identified�as the OWNER an this form. t also certify that all operations will be performed in accordance with�eafrc,PHSJEi ib hourly charges associated wtih this <br /> State and/or Federal Laws. applicable Ordinate Codes and/or Standards and <br /> APPLICANT'S SIGNATURE: -*7 ��y � � Datef <br /> - i <br /> r Program Records to be TRANSFERED: ` •$20.00= Amount Paid Date-/-/- <br /> Water System to be T/RANSFERED: •$372.00= Amount Paid Date 1 I <br /> Payment7T pse - Z / Check Number Received by 1 <br /> k !\ / / r <br /> COM S, —. l��t //�.r Date <br /> . - 1 I Account out: / �� <br /> COMMENTS: — �Date 49 � <br /> ' f <br /> i <br /> l <br /> E <br /> i <br /> C <br /> i <br /> f <br /> y� <br /> {L! <br /> _ f <br /> ' I <br /> 1k <br /> t <br /> } <br /> {5 <br /> IIPhs-ehsgl-nt}appslenvisionslreports15021.rpt <br /> _.) <br />