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i bateruni 1!1312009 3:47:55PA SAN JOA—=TIN COUNTY ENVIRONMENTAL HEAL''"'DEPARTMENT Report#5021 1 <br /> Run by <br /> Facility Information as of 1113/20 Pago3 <br /> Record Selection criteria: Facility to FA0003350 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator ocagent of same,acknowledge that all site,andlor project spec,PHSlEHD 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 aTI applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date / ! <br /> Payment Type Check Number Received by <br /> RENS: Date 1 1 Account out: [t-6, Date \ql a <br /> COMMENTS: <br /> " I <br /> i <br /> i <br /> l <br /> i <br /> I <br /> i <br /> i <br /> I <br /> I <br /> I <br /> 11eh-envlenvisionlreports15021.rpt <br /> 1 <br />