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e <br /> Date."" 2/18/2010 2:33:04PA SANJO/' IN COUNTY ENVIRONMENTAL HEAD Report#5029 <br /> - by DEPARTMENT ; <br /> Facility Information as of 2/1812010 Paget <br /> Record Selection Criteria: Facility ID FA0000620 <br /> BILLING,and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of some.acknowledge that all site,andlor project specific,PHSlEHD 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 he performed in accordance with ell applicable Ordinece Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> REHS: Date 1 I Account out: I/n7 Date ;2-- 10 <br /> COMMENTS: <br /> C <br /> II <br /> I <br /> i <br /> 1 <br /> i <br /> F <br /> 1 <br /> Ileh-envlenvisionlrepolts15021.rpt � <br />