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Date ran 3/27/2013 9:32:41M SAN JO' )UIN COUNTY ENVIRONMENTAL HEA' _Y DEPARTMENT Repo"#5021 <br /> .Run by , �,/ <br /> Facility Information as of 3/27/20'13 Paget <br /> Record Selection Critena: Facility ID FA0004506 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,endor project specific PHS/EHD hourly charges associated with this facility <br /> 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 Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date—/—I <br /> Payment Type Check Number Recelr7y/'fJf <br /> REHS: .K (D„ Date J /�` / 1') Account out: t�X Date / / <br /> COMMENTS: <br />