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Date run 4/23/2009 11:25:54AI SAN JO*IN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report 95021 <br /> Run by. . 4006 Page2 <br /> Facility Information as of 4/23/2 <br /> Record Selection Cnleria: Facility ID FA0004053 <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 acbNty will be billed to the parry identified as the OWNER on this farm. I also certify that all operations well 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: '$20.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / / <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-enNenvision\reports\5021.rpt <br />