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Date run 3/10/2009 11:42:44AI SAN JOA UIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> racility Information as of 3110120 Paget <br /> Record SeSection Criteria: Facility ID FA0004959 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'SSIGNATURE:Se-e- ft-OC n` T&�Ufw", _`v�9++ O.� Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date 1 I <br /> Payment Type Check Number f Received by_ <br /> REHS: Date 1 / Account out: Date 14 !O <br /> COMMENTS: i <br /> i <br /> } <br /> t <br /> i <br /> 11eh-envlenvisionlreports15021-rpt <br />