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Date run 5/3/2016 4:32:35PM SAN JOA N COUNTY ENVIRONMENTAL HEALfrEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 5/3/201 <br /> Record Selection Criteria: Facility ID FA0002112 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD hourly charges associated with this facility <br /> 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 Ordinance Codes andor Standards and State and'or <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 h ck Number Received by <br /> EHD Staff: Date_�/ /��, Account out: Date <br /> COMMENTS: Invoice <br />