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bate run 2/27/2014 11:25:13AI SAN JO. AN COUNTY ENVIRONMENTAL HEAI DEPARTMENT Report#5021 <br /> Run by <br /> Paget <br /> Facility Information as of 2/27/20 <br /> Record Selection Cntena: Facility ID FA0003749 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that al l site,andor project specific,PHSrEHD hourly charges associated with thisfacility <br /> or activity will be billed to the party identified as the OWNER on this fano. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment T e heck Number Receiv <br /> RENS: UI w� � Date Z- /�0/� Account out: Date 1— / r <br /> COMMENTS: T <br />