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Date rue_ 6/18/2010 1:35:33PASAN#UIN COUNTY ENVIRONMENTAL HEW DEPARTMENT <br /> Run by Facility Information as of 6/18Report#5021 <br /> Paget <br /> HE) <br /> Record Selection Criteria: Facility ID FA0003786 <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 /> State 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 at / <br /> Payment Type Check Number Receiv <br /> REHS: Date I Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />