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jate run 5121/2015 1M36PA SAN JC -)UIN COUNTY ENVIRONMENTAL HEA' `'[i DEPARTMENT Report#5021 <br /> by .. � Pege2 <br /> Facility Information as of 5/21/2tTT5 <br /> Record Selection Criteria Facility ID FA0006423 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of sameacknowledge that ani site,and/or project specific,PHSlEHO hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form !also certify that all operations will be performed in accordance witn all applicable Ordinance Codes and cr Standards and State andor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date �_/0;'y v� <br /> Program Records to be TRANSFERED. `$25.00= Amount Paid dZ031CO Date <br /> Water System to be TRANSFERED: Amount Pa �� Date <br /> Payment Type v Check Number Received Oy <br /> EHD Staff. Date I J Account out: Date l 1 <br /> COMMENTS: <br /> Invoice#: <br /> —�- V0 1-�. <br /> I zy- 10/1�e PAYIWEIVr <br /> �a li RECEf VEP <br /> JUN 0 4 2015 <br /> SAN JOAQjjjN C <br /> OUNry <br /> HEALITH i gR7/Aj <br />