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'Jatemn - 5/21/2015 3:06:36PR SAN JOWIN COUNTY ENVIRONMENTAL HEAR DEPARTMENT Rapo445021 <br /> . Run by Rage2 <br /> Facility Information as of 5/21/2015 <br /> Record Selection Criteria; Facility ID FA0006423 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned avow.operator oragent of same,ware ledge that all site,andor project specific,PHSEHD hourly charges aeeoclated with this facility <br /> oractivity 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 all applicable Ordswros Codes andor Standards and State ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: �,/o"t6 f. <br /> Program Records tobeTRANSFERED;. `$25.00= Amount Paid Z03•�Date <br /> Water System to be ITjANSFERED: Amount Paf Date / 7 6 <br /> Payment Type (/ Check Number Received <br /> EHD Staff; Date_� _� Account out: Date_J 5?�, jS <br /> COMMENTS: <br /> Invoice#,. <br /> PAYIME <br /> � gD <br /> 0 4 2015 <br /> SAN /p <br /> EN�AOU/1WIN COUlyrV <br /> kEALTH pE AR MEQ <br />