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Date run 9/28/2015 11:09:26AI SA�UIN COUNTY ENVIRONMENTAL)�DEPARTMENT Report#5021 <br /> Paget <br /> R°"by Facility Information as of 9/28/20 5 <br /> Record Selection Criteria: Facility ID FA0013628 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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 andfor Standards and State andfor <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 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date_/_/_ Account out: Date <br /> COMMENTS: Invoice 1F: <br />