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Date un *10/19/2018 4:58:26P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Paget <br />Facility Information as of 10/19/2018 <br />Record Selection Criteria: Facility ID FA0006174 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, ancl/or project specific, PHS/EHD 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 and/or Standards and State andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: * $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received bv <br />EHD Staff: Z— Date 16) / l l Account out: Date 0 <br />COMMENTS: <br />Invoice #: <br />