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Daterun 718/201510:18:37AM SA*QUIN COUNTY ENVIRONMENTAL I&TH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 7/8/2015 <br /> Record Selection Criteria: Facility ID FA0006943 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project speck,PHSIEHO 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 Nat all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State anclor <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 Type Check Number Received by <br /> EHD Staff: Date_/_/_ Account out: Date <br /> COMMENTS: Invoice#: <br />