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Date run 10/16/2012 10:27:04Y SAN JUIN COUNTY ENVIRONMENTAL HE <br /> Run by Paget"H DEPARTMENT Report#5021 <br /> F�cilgy Information as of 10116 112 <br /> Record Selection Criteria: Facility ID FAOOD4959 I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge thatail site,andfor 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 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andror <br /> Federal Laws. <br /> APPLICANTS SIGNAT E• Date <br /> Program Records to be TRA FERED: *$25.00= A5- Amount Paid MILE— Date <br /> Water System to be TRANSFERED: Amount Paid Date / ! <br /> Payment Ty c" &er Receiv d by 1 <br /> REHS` Date v 1 ! vAccount out: Date ! / <br /> COMMENTS: <br /> 1 <br /> PAYMENT <br /> RECEIVED <br /> o` OCT 16 202 <br /> Jj <br /> SAHJOAOHM COUNNTA,LIY <br /> EMIIRONkI£NTAL <br /> HEALTH DEPARTMENT <br /> I <br />