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Date run 12/17/2014 9:24:50A SAN J IN COUNTY ENVIRONMENTAL HEA Report#5021 DEPARTMENT Pagaz <br /> Run by <br /> Facility Information as of 12/1712014 <br /> Record Selection Criteria: Facility ID FA0003732 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHS'EHD 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 Codes 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 Check Number Received by <br /> RENS: Date ... /_/_ Account out: Date_/ / <br /> COMMENTS: <br />