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Dal an 10/9/2014 11:15:14AI SAN J WIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> R' oy 1273 Paget <br /> Facility Information as of 10/9/2014 <br /> Record Selection Criteria: Facility ID FA0010273 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> Of 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 anddor Standards and State ando, <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! I_ <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 Receiv <br /> REHS: Date_/ / Account out: Date / <br /> COMMENTS: <br />