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Date run 7/21/2015 9:57:46AN SAr*AQUIN COUNTY ENVIRONMENTAL IWTH DEPARTMENT <br /> Report#5021 <br /> Run by <br /> Facility Information as of 7/21/2015 Paget <br /> Record Selection Catena: Facility ID FA0002232 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andbr project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. I also certgy that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State anctor <br /> Federal Laws <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment TypeEHD Check Number Received by <br /> COM Staff: Date / / Account out: Date <br /> COMMENTS: --- <br /> Invoice#: <br />