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Date run 6/29/2015 9:16:44AK SAN JOA 'IN COUNTY ENVIRONMENTAL HEALT DEPARTMENT Report#5021 <br /> Run by� Page2 <br /> Facility Information as of 6/29/201 <br /> Record Selection Criteria: Facility ID FA0003681 <br /> BILLING and COMPLOACE ACKNOWLEDGEMENT: I,the undersigned!owner,operator or agent of same,acknowledge that all site,andor project specific,PHSrEHD hourly charges associated with this facility <br /> or activity will be billedto the party ldenlrfied as the OWNER on Oisform. l also certify that all operations will be performeam accordance with all applicable Ordinance Codes anNor 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 />