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Date run 2/13/2014 11:48:57AI SAN JO UIN COUNTY ENVIRONMENTAL HEAL -1 DEPARTMENT Report#5021 <br /> Run by I Paget <br /> Facility Information as of 2/13/2014 <br /> Record Selection Criteria: Facility ID FA0004175 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andtor project specific,PHSIEHD hourly charges associated with this facility <br /> 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 Ordinance Codes andlor Standards and State anclor <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 .Receive <br /> REHS: Date Account out: Date_1 /cW <br /> COMMENTS: <br />