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i Dr arun x.12129/2009 10:21:30/ SAN JO' 'UIN COUNTY ENVIRONMENTAL HEA' 4 DEPARTMENT Report#sozl <br /> Run by Paget <br /> Facility Information as of 12/29/2009 <br /> Record Selection Criteria: Facility ID FA0018043 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHE)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 Ordinace Codes and for Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 ! <br /> Program Records to be TRANS RED: *$20.00= Amount Paid Date 1 1 <br /> Water System tie TRA ED: *$372.00 Amount Paid Date <br /> Payment T e Check Number Received by <br /> RENS: ..Ga Date-a I Account out: Date <br /> COMMENTS: <br /> I• <br /> k�r <br /> i <br /> i <br /> k <br /> I <br /> i <br /> I <br /> h. <br /> r <br /> k <br /> Neh-envlenvisionlreports15021.rpt <br /> i' <br />