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Date run 9/3/2015 3:58:15PM SAN JOAN COUNTY ENVIRONMENTAL HEALOEPARTMENT Repofl#sozi <br /> Run by Paget <br /> Facility Information as of 9/3/2015 <br /> Record Selection Criteria: Facility ID FA0011022 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as Me OWNER on this form l 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 /> EHD Staff: Date_/_/ Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />