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Dateruf ;/17/2012 3.56:21PI\ SAN JOAn1JIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by ' Paget <br /> Facility Information as of 1/17/20 <br /> Record Selection Criteria: Facility ID FA0000229 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or 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 Typ Check Number Re e' ed by <br /> REHS: I" L Date A / I ! Account out: q— Date�_/ !i 0/ �L <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />