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Date run 2/1/2016 3:12:41PM SAN JOIN COUNTY ENVIRONMENTAL HEAIJPDEPARTMENT Report#5021 <br /> V..uo by ` Page2 <br /> Facility Information as of 2/1/201 <br /> Record Selection Criteria: Facility ID FA0002971 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or 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. l also certify that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards and State andlor <br /> Federal Laws <br /> APPLICANTS 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 b <br /> EHD Staff: -' l Date Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />