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D "'^ 10/30/2012 2:51:55F <br /> Run by SAN JO UIN COUNTY ENVIRONMENTAL HEAL"'A DEPARTMENT <br /> Reportf5021 <br /> Record Selection <br /> Facility Information as of 10/30/2012 Paget <br /> Cr(terta: Facility ID FA0006171 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator oragent o/acme <br /> F�Willi Abe bflad to the Darty identified as the OWNER on this form I also certify that all agogOPOro s wig #W all aka,ardor Prot SPWVc,PHMHO harly,&WIM UNdSW vAth p�facility <br /> performed in axordar"with all applicable Ordwta m Cody www Standards and State ardor <br /> APPLICANTS SIGNATURE: <br /> Program Records to be TRANSFERED: •$25.00= <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Date <br /> Payment Type Check Number Amount Paid Date / <br /> RENS: V ( Received by <br /> COMMENTS: <br /> Date�Q_/ / Amount out: Date / <br /> / <br /> ,q(4 ft�A6b �rf-I-- p <br /> IV <br /> �• Mi r 1 � V If( �'r`- y <br />