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Date nun 7/15/2015 3:28:56Ptu SAifAQUIN COUNTY ENVIRONMENTALITH DEPARTMENT Report#5021 <br /> Run by !� Paget <br /> Facility Information as of 7/15/2015 <br /> Record Selection Crileda: Facility ID FA0002347 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor 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 Nat all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State ancror <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: <br /> Invoice#: <br />