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.� Date r n -7,842010 8:43:39AM SAN JP ' )UIN COUNTY ENVIRONMENTAL HEA'711 DEPARTMENT Keponrfauci <br /> Run dY',. Paget <br /> Facility Information as of 8/4/2 <br /> fj Record Selection Criteria: Facility ID FA0002971 <br /> { BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEHD hourly charges associated with this <br /> facility or activity wiB be billed to the party identified as the OWNER on this form. I also certify that all operations wilt be performed in accordance with all applicable Ordinate Codes andfor Standards and <br /> a State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: - Date C151b, 1 0 1 10 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date 1 1 J <br />' Payment Ty Check Number Re by <br /> FW <br /> REH Date Account out: — Date 1 1 <br />{ COMMENTS: <br /># �I <br /> �i <br /> I it <br /> y <br /> t -- <br /> t <br /> a' <br /> i <br /> i <br /> I <br /> 1 <br /> Y J <br /> i� <br /> 1 <br /> iE :] <br /> 1 r <br /> F <br />{ <br /> \\eh-env\envision\reportsk5021.rpt <br /> t <br />