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Date run 1/21/2010 6:51:16AM1 SAN 4VUIN COUNTY ENVIRONMENTAL HF4V DEPARTMENT <br />Repon #5027 <br />Run by Page2 <br />Facility Information as of 1/21/20'1.. <br />Record Selection Criteria: Facility ID FA0006943 <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 <br />facility or actMty will be billed to the party identified as the OWNER on this form. I alsocettify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br />State andfor Federal Laws. A <br />COMMENTS <br />PAYMENT <br />RECEIVED <br />FEB 10 2010 <br />SAN <br />EN'AARONMENTALTM <br />HEALTH DEPARTMENT <br />\\eh-env\en vi cion\reoorts\5021. rot <br />APPLICANT'S SIGNATURE`-^ <br />Program Records to be TRANSF R <br />) 4� <br />Date <br />1t� 2ll %�1 <br />' $20.00 = <br />Amount Paid? ' Date <br />JDate <br />Water System to be TWjNSFERED: <br />' $372.00 = Amount Paid <br />Payment Type ,/ <br />Check Number — — <br />Received by <br />RENS: <br />Date 104/ 1 <br />Account out: <br />Date <br />COMMENTS <br />PAYMENT <br />RECEIVED <br />FEB 10 2010 <br />SAN <br />EN'AARONMENTALTM <br />HEALTH DEPARTMENT <br />\\eh-env\en vi cion\reoorts\5021. rot <br />