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Dstean .,; 311@011 2:13:32PM SAN JWUIN COI;NTY ENVIRONMENTAL HE&H DEPARTMENT Repona5021 <br /> 273 <br /> -Run-by 1Page2 <br /> Facility Information as of 3/112011 <br /> Record Selection Criteria; Facility ID FA0001705 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner.operator or agent of same,acknowledge Nat dl site.end/or Project spedac,PHSIEHD houdycherges associated with this <br /> facility a activity will be billed to the party Identified m the OWNER on this form. I also carbfy,that all operations will be pedormed in accordance with all applicable Ordinace Codes and/a Standards and <br /> Slate 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 Receive / <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />