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Date nun _6/8/2015' 12:23:01PU SAN JO y TIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by VO' h"I'llf Paget <br /> Facility Information as of 6/8/2015 <br /> Record Selection Criteria: Facility ID FA0003299 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHSEHD hourly charges associated withthisfacility <br /> or activity will 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 Ordinance Codes andor Standards and State ander <br /> 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 Received by <br /> EHD Staff: Date / / Account out: Date / / <br /> COMMENTS: <br /> Invoice#: <br />