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Data run 11/32016 8:14:42AIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report i15Cz1 <br /> Run by Pege2 <br /> Facility Information as of 11/3/2016 <br /> Record Selection Criteria: Facility ID FA0000380 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT' 1,the undersigned owner,operator or agent of same,sanowledge that all site,andor project specific,PHS/EHD hourly charges associated with Nis facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also cerl that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State anchor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date_I / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Tyq� Check Number 11 Received <br /> EHD Staff: 1�1 _ Date Account out: Date <br /> COMMENTS: Invoice#: <br />