Laserfiche WebLink
Date run 12/7/2015 2:25:05PA SAN JO A 9M COUNTY ENVIRONMENTAL HEA'"H DEPARTMENT <br /> Run by Report#5021 <br /> Facility Information as of 12/7/2u 15 Page2 <br /> Record Selection Criteria: Facility ID FA0004254 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSrEHD 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 all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State andlor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: 6� /Jy I Date <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount PaidDate <br /> Payment Type eck N tuber Received b <br /> EHD Sta#i-- o'Ks! ,_ Date_�/ / tr Account out: Date / �� <br /> COMMENTS: <br /> Invoice#: <br />