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Date run rTt0/2014 11:42:30AI SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run liy 1273 Page2 <br /> Facility Information as of 2110120 4 <br /> Record Selection Criteria: Facility ID FA0000187 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party idenEfied as the OWNER on this form. I 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 /> APPLICANT'S SIGNATURE: Date / ! <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> REH Date 0 4L Account out: Date 1 ! <br /> COMMENTS: <br />