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Date run 2/27/2014 11:25:13AI SAN JO: N COUNTY ENVIRONMENTAL HEAI DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 2/27/2014 <br /> Record Selection Criteria: Facility ID FA0003749 <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 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 and(or Standards and State and'or <br /> 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 T e heck Number Receiv d <br /> REHS: z� �,U.— Date 2.- /1, J)�4 Account ouk Date �L— eLf- <br /> COMMENTS: <br /> T—(— <br />