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Date run 11/10/2011 4:02:23P SAN JO A OUIN COUNTY ENVIRONMENTAL HEAL 'rH DEPARTMENT Report #5021 <br />Run by � Page2 <br />Facility Information as of 11/10/ <br />Record Selection Criteria: Facility ID FA0003978 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this <br />facility 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 Ordinace Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 Recei /l <br />REHS: M ' ti4K4- Date 11 / / / Account out: Date <br />COMMENTS: <br />\\eh-env\envision\reports\5021. rpt <br />