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Oe.a run '1/31/2013 12:41:32PI SAN JC 'NUIN COUNTY ENVIRONMENTAL HEA' J DEPARTMENT ReportkbOzt <br /> Run by `r" Paget <br /> Facility Information as of 1/31/20T3 <br /> Record Selection Criteria: Facility ID FA0007213 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific.PHSIEHD 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 that ell operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State endfor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type// Check Number Rece07 <br /> REHHS: G.� L Date l � _11,3— Account out: Date <br /> CppJIrENTS .. / _ <br /> r <br /> r <br />