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} Date run 2/23/2010 11:06:12AI SAN JO/").UIN COUNTY ENVIRONMENTAL HEAL 7'9 DEPARTMENT Report 95021 <br /> Run by ` <br /> Imo, Facility Information as of 2/23/20 Paget <br /> Record Selection Criteria: Facility ID FA0001554 f <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSlEHD hourly charges associated with this <br /> Facility 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 Ordinate Codes andlor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: y Date 1 ! <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid r Date 1 1 <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date ! f <br /> Payment Type Check Number Received by <br /> RENS: Date 1 1 Account out: i Date 1 I <br /> COMMENTS: <br /> I <br /> e <br /> I <br /> E <br /> f <br /> r <br /> s <br /> kleh-envlenvisionlreports15021.rpt <br />