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Date run 6/16/2010 3:54:50PN SAN JUIN COUNTY ENVIRONMENTAL HE*- H DEPARTMENT Report#5021 <br /> Run by Page2 <br /> Facility Information as of 6/16/ <br /> Record Selection Criteria: Facility ID FA0004959 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,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 a}I operations will be performed in accordance with all applicable Ordinate Codes andlor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFE RED: '$372.00= Amount Paid Date 1 1 <br /> Payment T e Check Number Recei f <br /> RENS: �t V V Till t rte+ Date Account out: Date <br /> COMMENTS: fll�� 6-ccavretw), aA <br /> otb ' m <br /> r <br /> lleh-envlenvisionlreports15021.rpt <br />