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[Record <br /> run,. 12!17120107Facllity <br /> A SAN Jr 1UIN COUNTY ENVIRONMENTAL HEA,- `-Tq DEPARTMENT <br /> ty Report#5021 <br /> � Page3 ] <br /> Facility Information as of 12/17/200 <br /> Selection Criteria: FAD003350 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD 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 a[I applicable Ordinate Codes and for Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 a <br /> � Pa ment T e � <br /> Y Yp Check Number Received by <br /> RENS: <br /> Date L_! 7/�p` Account out: ^ Date i'L/ ? I 1 D <br /> COMME S: � <br /> �'N a <br /> Nom,.►y.....��. a��c.�L_� ��w Pim rs vtc.+x,.��. ; <br /> { <br /> t. <br /> I <br /> } <br /> I <br /> I <br /> L i <br /> f <br /> I <br /> I+F, <br /> 4.. <br />'r <br /> 11eh-envlenvisionlreports15021.rpt <br /> t <br />