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Date run 4/21/2017 8:18:40AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repan*5021 <br /> Run by <br /> Facility Information as of 4/21/2017 Paget <br /> Record Selection Criteria: Facility ID FA0005626 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSrEHD hourly charges associated with this facility <br /> or acliylly will be billed to the party identiFed as the OWNER on this form. I also certify that all operations will be performed in accordance withal(applicable Ordinance Codes andor Standards and State andor <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 Che Number Received by <br /> EHD Staff: Date L4 / _/�� Account out: Date 11244/1- <br /> COMMENTS: <br /> Invoice#: <br />