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ERecordSelecOon <br /> /2009 10.16:42M SANJOAA COUNTY ENVIRONMENTAL HEALi' EPARTMENT Report#W21 <br /> Facility Information as of 12/9/2009 �e2 <br /> iteria: Facility ID FA0006832 <br /> r BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same acknowledge that all site,and/or project ed6c,PHS/EHD hourly ch <br /> facility or activity will be billed to the party Identified as the OWNER on this form, 18180 Card that all P°f gP Y arge9 associated with this <br /> State and/or Federal Laws, fY operations will be peAormed In accord with all applicable Ordinate Codes andlor Standards and <br /> APPLICANT'S SIGNATURE: 71�i <br /> Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be T ANSFERED: `$372.00= Amount Paid pate / ! <br /> Pay <br /> men Check Number Received <br /> REM. Date�a ! 7c� IdJ�' <br /> Account out: pate <br /> COMMENTS: <br /> a <br /> h <br /> f <br /> h <br /> ' F <br /> I%eh-envlenvisionVaport515021.rpt }1 <br /> -J <br />