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DatErun 10 2014 11:14:33AI , SAN JO - `UIN COUNTY ENVIRONMENTAL HEAP ---1 DEPARTMENT Report R5021 <br /> Run bya 12iS Sa/ Page2 <br /> Facility Information as of 10/9/201' <br /> Record Selection Criteria'. Facility ID FA0001705 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify Nat all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Type Check Number Receiv y <br /> RENS: Date / / Account out: Date:: �/ / <br /> COMMENTS: <br />