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'Dsterun ` 6/7/2016 10:00:40AIV SAN JOAqW COUNTY ENVIRONMENTAL HEALTf#EPARTMENT Report#5021 <br />Run by Paget <br />Facility Information as of 6/7/2016 <br />Record'Selection Criteria: Facility ID FA0003726 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, anc for project specific, PHSIEHD 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 anNor Standards and State andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Date 06 <br />Program Records to be TRANSFERED: $25.00 = Amount Paid Date <br />Water System to be TRAAdSFERED: Amount Pai a�Date 6 ZO <br />Payment Type ✓ Check Number /b Received b <br />EHD Staff: (� Pa_ /�-71�i,Date _& L tr�/� Account out: Date 4 <br />COMMENTS: <br />Invoice #: <br />