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Date nun 11/14/200810:09:08/ SAN JQAnUIN COUNTY ENVIRONMENTAL HEALT4 DEPARTMENT Repnft n5U21 <br /> Run In, I I Page? <br /> '111111110, Facility Information as of 11/14/20%W <br /> Record Selection Criteria'. Facility ID FA0001783 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner.operator or agent of same,acknowledge that an site,and/or project specific.PHSIEHD hourly charges associated with uns <br /> facility w activity,volt be billed to the parry identified as the OWNER on this fdrrn. I also certify that all operations wilt be performed in accordance with all applicable Ordinace Codes ancior Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Reoords to be TRANSFERED: '$20.00= Amount Paid Date—1—/ <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type � Check Number Race y <br /> REHS: \ � Date�/��/ Account out: Date / / <br /> COMMENTS: <br /> \\phs-ehsq I-n I\apps\envisions\reports\5021.rpt <br />