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e <br /> run 4/13/2010 4:10:17PN SAN J 2UIN COUNTY ENVIRONMENTAL HE fH DEPARTMENT Report#5021 <br /> by <br /> Facility Information as of 4/13/2010 Paget <br /> Record Selection Criteria: Facility ID FA0004518 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,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 all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> Slate and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: `$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date l / I3 / -�-O/J Account out: �rL Date /�/l <br /> COMMENTS: <br />