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Date run 5/29/2012 4:05:24PR SAN JUIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report 95021 <br />Run by Paget <br />` Facility Information as of 5/29/2012" <br />Record Selection Criteria: Facility ID FA0000187 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor project specific, PHSIEHD hourly charges associated with this facility <br />or activity will bebilEed to ti party identified as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anti Standards and State andlor <br />Federal i <br />APPLICANT'S SIGNATURE: Date 1 ! <br />Program Records to be TRANSFERED: " $25.00 = Amount Paid Date 1 I <br />Water System to be TRANSFERED: Amount Paid Date 1 ! <br />Payment Type Check Number Recei ;119- <br />REHS: Date Pl„1`2A Account out: Date ! o � 16;21 <br />COMMENTS: v <br />r <br />