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Dar an 1!1/9/2014 1'1:15:14A1 SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Repot#5o21 <br /> R 'It 273 T Paget <br /> Facility Information as of 10/9/201 <br /> Record Selection Criteria: Facility ID FA0010273 <br /> operator oragent of same,acknowledge that all site,ander project specific,PHSEHD hourly charges associated with this facility <br /> BILLING entl COMPLIANCE ACKNOWLEDGEMENT: I,theER on this <br /> owner, pe <br /> or activity will be billed to the party identified as the OWNER an this farm. I also certify,that all operations will be performed in accordance with all applicable Ortlinanca Codes ander Standards and Stale en or <br /> Fecarel Laws. <br /> APPLICANTS 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 Recely -L <br /> REHS: Date_/_/_ Account out: <br /> COMMENTS: <br />