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Date mn 5/28/2008 9:14:44Ah SAN JO IN COUNTY ENVIRONMENTAL HEAI f DEPARTMENT Report#5021 <br /> RurrrbyPaget <br /> ' Facility Information as of 5/28/2008 <br /> Record Selection Criteria: Facility ID FA0009294 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknoWedge that all site,and/or project spec,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 Ormnace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Rece <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />