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Date run 10/17!2011 11:30:33{ SAN JUIN COUNTY ENVIRONMENTAL HE H DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 101171c 1 <br /> Record Selection Criteria: Facility ID FA0004959 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific.PHSIEHD 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 Godes and/or Standards and <br /> State andlor Federal Laws. (� F <br /> APPLICANT'S SIGNATURE: !I ' c��l Date ! 1 7 <br /> Program Records to be TRANSFERED: '$25.00 Amount Paid Date 1 1 <br /> Water System to be T�RLANSFERED: Dunt Paidd�5_ Date /0 1 1-7 <br /> �tti I <br /> Payment Type � Check Number Recei y <br /> RENS: T.2f Date 1011'1 t f Account out: Date X1,91 1-7 <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> [ � iOCT 172011 <br /> ` sAwaonaur�ca��•, <br /> !HEALTH DEr'A'.`i lm <br /> i <br /> Ileh-envlenvisionlreports15021.rpt <br />