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r <br />run 4/13/2010 4:10:17Ph SAN J )UIN COUNTY ENVIRONMENTAL HE. lH DEPARTMENT Report#5021 <br />by Paget <br />Facility Information as of 4/13/2010 <br />/ Record Selection Criteria: Facility ID FA0004518 <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 <br />facility 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 Ordinace Codes and/or Standards and <br />State and/or Federal Laws, <br />APPLICANTS SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: I * $20.00 = Amount Paid Date <br />Water System to be TRANSFERED: * $372.00 = Amount Paid Date <br />Payment Type Check Number Received by <br />REHS: 'Vs -`1d 2,0 Date �/ %3 / /J Account out: 7.L Date 1514 / � 11 � <br />COMMENTS: <br />