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Date run 3/10/2016 12:25:36PI SAN JOA— `IN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Report#5021 <br /> Run by ' Page2 <br /> Facility Information as of 3/10/2016 <br /> Record Selection Criteria: Facility ID FA0009619 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD 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 ancVor Standards and State andtor <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 Received by <br /> EHD Staff: Date 3 / /0/ Account out: 14d2 Date / <br /> COMMENTS: <br /> Invoice#: <br />