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Rate run 2/18/2009 9:12:16AA <br /> Runby �SAN J QUIN COUNTY ENVIRONMENTAL HE#H DEPARTMENT Report#5021 <br /> Facility Information as of 21181 Page2 <br /> Record Selection Criteria: Facility ID FA0004959 <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 Wit 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date 1 I <br /> Payment Type Check Number Receiv <br /> REHS: Date II t Account out: Date 1� 1 <br /> COMMENTS: <br /> ZOO, <br /> 641 'Pill <br /> 1 <br /> Ileh-envlenvisionlreports15021.rpt <br />