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Date nn 2/19/2016 8:25:20Ak SAN J(SUIN COUNTY ENVIRONMENTAL HE H DEPARTMENT Report#5021 <br /> Paget <br /> Run by <br /> Facility Information as of 21191 <br /> Record Selection Criteria: Facility ID FA0009860 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project speck,PHSfEHD 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 artier Standards and State antler <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 Type — ,,//CCheck Number Received byI, <br /> EHD Staff: `rx aw Date / / Account out: Vl Date <br /> COMMENTS: Invoice#: <br />