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Datemn 1/28/2011 11:28:40AI SAN X UIN COUNTY ENVIRONMENTAL HEAD, DEPARTMENT ReporlXK21 <br /> R.by 5290 Page2 <br /> Facility Information as of 1/28/2011 <br /> Remrtl Selection Criteria: Facility ID FA0009750 <br /> BILLING arb COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that an site,and/or project spedfk.PHSIEND hourty charges associated With this <br /> facility or adlvlty,will be bitted to the party Identified as the OWNER on this form. I also cantly that all operations will be performed In accordance with 0 applk'able Ord'mace Codes aMlor Standards arM <br /> State wW"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 ReceiveQ tpt <br /> REHS: Date I I Account out Date <br /> COMMENTS: <br /> \1eh-env\envision\reports\5021.m t <br />