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Date run 8ry4/2014 3:31:OOPt1 SAN JO IN COUNTY ENVIRONMENTAL HEAL 'DEPARTMENT <br /> Report#5021 <br /> Run by *"10 Page2 <br /> Facility Information as of 8/14/2014 <br /> Record Selection Criteria: Facility ID FA0000086 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <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 Cortes 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 edCheck Number Rece1 <br /> REHS: S Date / / Account out: Date <br /> COMMENTS: <br /> �E Rvs3`1341 <br />