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Date run 10,42014 11:14:33A1 SAN JCfAN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by 12id Paget <br /> Facility Information as of 10/9/20'14 <br /> Record Selection Criteria: Facility ID FA0001705 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project spec,PHStEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also cenify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State anclar <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: 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 Receiv y <br /> REHS: Date Account Account out: — Date / /4 <br /> COMMENTS: <br />