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i <br />Date run 2/16/2016 3:05:10PR SAN JO —UIN COUNTY ENVIRONMENTAL HEA' ^"1 DEPARTMENT Report#5021 <br />.. Run by • Page2 <br />Facility Information as of 2/16/20 <br />Record Selection Criteria: Facility ID FA0003678 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror project specific, PHSrEHD 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 andlor <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 Check Number Received by <br />EHD Staff: Date / / Account out: Date <br />COMMENTS: <br />Invoice #: <br />