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Date run 7/16/2015 4:00:31PN SAIN QUIN COUNTY ENVIRONMENTALHOT H DEPARTMENT Report#52t <br /> Run by `' Page2 <br /> Facility Information as of 7/16/2015 <br /> Record Selection Criteria: FacilityID FA0003717 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project speck,PHSIEHD hourly charges associated with thn 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 and'or Standards and State andor <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 /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />