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Date run 3/20/2013 4:45:28PR SAN JOi`oeIN COUNTY ENVIRONMENTAL HEAL— 'DEPARTMENT Report 85021 <br /> Run by Paget <br /> Facility Information as of 3/20/20 <br /> Record Selection Criteria: Facility ID FA0004506 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,endor project specific,PHSIEHO 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 Lewis <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 <br /> Payment Type Check Number Received y <br /> RENS: Date / / Account out: Date <br /> COMMENTS: <br />