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Date tun 1/11/2016 8:28:41M SAN JOCOUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by �I Page2 <br /> Facility Information as of 1/11/2016 <br /> Record Selection Criteria: Facility ID FA0010287 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project speck,PHSIEHD hourly charges associated with this facility <br /> or activity will ba 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 ander Standards and State ardor <br /> Federal Laws <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date_/ I <br /> Water System to be TRANSFERED: Amount Paid Date ! / <br /> Payment Type Check Number Received by <br /> EHD Staff: Date IF Account out: Date_/ / <br /> COMMENTS: <br /> Invoice II <br />