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` Date r 12/23/2009 8:30:38Af SAN JO/ IN COUNTY ENVIRONMENTAL HEAI1. DEPARTMENT <br /> Report JO'SQ21 <br /> tiRrsi by �- ' <br /> Facility Information as of 12/23/20�M Paee2 <br /> Record Selection Criteria: Facility ID FA0000620 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acim wled a that all site,and/or project <br /> facility or aWiAty will be billed to the party Identified as the OWNER on this form. I also certify that all g p W specific,PHSlEHD hourly charges assodeted with this <br /> State end/or Federal Laws. fY operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <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 /> T Payment Type Check Number Received by <br /> REH • Date Z/_��1 Account out: Date-A 2./ 2►3/ G'l <br /> COMMENTS: <br /> ,' kk <br /> I <br /> f <br /> G <br /> i <br /> i <br /> ps 1 <br /> IL I <br /> t <br /> 1Heh-env%envisionVeportsM21.rpt <br /> j <br />