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Date run 3/1/2016 9:55:07AM SAN JO IN COUNTY ENVIRONMENTAL HEALWEPARTMENT Reponu5021 <br /> Run by - Page2 <br /> Facility Information as of 3/1/2016 <br /> Record Selection coterie: Facility ID FA0001705 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHSEHO hourly charges associated with Nis 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 andror Standards and Stele andror <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—1 / <br /> Payment Type Check Number Received by <br /> EHD Staff: /�_ i/T Date_ /�/ Accountout: �_ Date 3/�/� <br /> COMMENTS: <br /> Invoice# <br />