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Date run 911/2015 10:07:50AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report#5021 <br /> Facility Information as of 9/1/2015 Paget <br /> Record Selection Criteria: Facility ID FA0009333 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all ate,an6'or project spectre.PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identtred as the ONAER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anclar Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S 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 /> COM Staff: Date_/ / Account out: Date <br /> COMMENTS: --- <br /> Invoice#: <br />