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Date run 12/15/2009 4:17:48F SAN.IOAC 'Y COUNTY ENVIRONMENTAL HEALTV —EPARTMENT Report 45021 <br /> Run by � � Page3 <br /> Facility Information as of 12/15/200 " <br /> 4 <br /> Record Selection criteria: Facility ID FA0003350 <br /> 1 BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of Same,acknowledge that ail site,andlor project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWN FR on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> i . . <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be T SFERED: `$20.00= Amount Paid Date / 1 <br /> Water Syste o be AN ERED: "$372.00= Amount Paid Date 1 1 t <br /> Pay nt Type <br /> Check Number Received by <br /> RE : Datel 1 Clf Account out: Date 12-1 1 112109� <br /> COMMENTS: <br /> i <br /> 76 <br /> . I <br /> } <br /> � I <br /> I <br /> . I <br /> l <br /> t <br /> i <br /> Ileh-envlenvisionlreports15021.rpt <br />