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Date run 2/13/2017 1:06:31 PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#50211 <br /> Run by <br /> Facility Information as of 2/13/2017 Paget <br /> Record!Selection Criteria: Facility ID FA0009333 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent d same,acknowledge that all site,andfor prated specific,PHSIEHO hourly charges associated with this facility <br /> or activity will be billed to Ne Party identified as the OWNER on this form I also certify that all operations will be performed In accordance with all applicable Ordinance Codes an l Standards and State anclor <br /> Federal Laws, <br /> APPLICANTS SIGNATURE: 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 by <br /> EHD Staff: Date_/ /_ Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />