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Date run 6/7/2016 10:00:40AM SAN JOAC "N COUNTY ENVIRONMENTAL HEALT' 'IEPARTMENT Report#5021 <br /> Run by Psge2 <br /> Facility Information as of 6/7/2016 <br /> Record-Selection Criteria: Facility ID FA0003726 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,anchor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will he billed to the party identified as the OWNER on this form I aim certify that all operations will be perforrnetl in accordance with all applicable Ordinance Codes anchor Standards and State anchor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Pai 1;41 R.QPDate <br /> Payment Type, —�✓-�Check Number 161&/' Received b / <br /> EHD Staff: c-��(AI kR V) —A.)1 &Date yam/_t lam/ Account out: Date l Zl1� <br /> COMMENTS: <br /> Invoice <br />