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rDate_run_� IZ2912008 9:46:05AI SAN 3f UIN COUNTY ENVIRONMENTAL HE/ H DEPARTMENT Report#5021 <br /> Run by Page3 <br /> Facility Information as of 12/29/206 <br /> Record Selection Criteria: Facility ID FA0003350 <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 activfty 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 vJI applicable Ordinace Codes and/or Standards and } <br /> State and/or Federal Laws. <br /> 1 <br /> APPLICANT'S SIGNATURE: Date 1 / <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date 1 I <br /> Payment Type Check Number Received by <br /> REHS: Date 1 ! Account out: Date 1 1 <br /> COMMENTS: <br /> I <br /> I <br /> I <br /> i <br /> I <br /> I <br /> I <br /> II <br /> f <br /> I <br /> I <br /> I <br /> { <br /> r <br /> Ileh-envlenvision\Reports15021.rpt <br /> i <br />