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agN 11/17/2009 4:11:18PISAN JC"' <br /> IN COUNTY ENVIRONMENTAL HEA' 'i DEPARTMENT <br /> Run R�0"i°' ' <br /> by Page2 <br /> Facility Information as of 11/17/2009 <br /> Record Selection Criteria: Facility ID FA0000229 <br /> I BILLING and COMPLIANCE ACKNOWLEDGEMENT: i,the underslgned 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 farm. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 0�7 <br /> Program Records to be TRANSFERED: $20.00= Am aid Date / 1 <br /> W at yste��be TRA FERED: "$372.00= Amou►rt Paid Date ! ! f <br /> l I <br /> P ent T Check Number Received by <br /> R HS: Date /� 1�?.j 1 Alp, out: <br />{ CO S. <br /> t <br /> k <br /> i <br /> I <br />{ <br /> l <br /> r <br /> I <br /> F <br /> I <br /> i <br /> i <br /> 7 {! <br />{ , <br /> j' 11eh-envlenvisionVepons15021.rpt } <br />