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Date run 2/13/2014 1 t:48:57A1 SAN JOReport#5021 <br /> IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Page2 <br /> Run by � ' �I <br /> Facility Information as of 2/13/2OF4 <br /> Record Selection Crifena: Facility ID FA0004175 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Me undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,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 that all operations will be perfumed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 Recei <br /> REHS: Date / / Account out: Date 0 <br /> COMMENTS: T <br />