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Date run 8/2/2011 12:50:58PM SAN JO" �UIN COUNTY ENVIRONMENTAL HEAI "''DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 8/2/201 <br /> Record Selection Criteria: Facility ID FA0009566 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or 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 Type Check Number Recei y <br /> RENS: Date -n' / ?� / Account out: Date / / <br /> COMMENTS: <br /> \\eh-env\en vision\reports\5021.rpt <br />