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Date lin 15/22/2014 141.26PA SAN JO'lli%I1IN COUNTY ENVIRONMENTAL HEAL,JDEPARTMENT Report#5022 <br /> Run by Page2 <br /> CIW Proodssed Information on 5/22/2014 <br /> Record Selection Criteria: Facility ID FA0015750 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed!to Me party identified as the OWNER on this form lasso certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Lewis <br /> APPLICANT'S 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 Remi _ <br /> REHS: Date I / Account out: Date / /, I�..I _ <br /> 0 Create file for New Program Record. Date Completed: Name: <br /> Add Business Plan. Date Completed: Name: <br /> Route to Accounting for: Billing Permit. Date Completed: Name: <br /> NOTES: NEW INFORMATION IN RED FONT <br />