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Date run 5/9/2017 12:59:40PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repon#5021 <br /> Run by Page2 <br /> Facility Information as of 5/9/2017 <br /> Record Sedcfion Criteria: Facility ID FA0009860 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersgnetl owner,operator or agent of same,acknowledge that all site,andor project specific.PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards and State ander <br /> Federal Lewis <br /> APPLICANTS SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type I_Check Number Received IDWn <br /> EHD Staff: Mate. Date-5-/--q-/—L7— Account out: Data <br /> /49 / /7 <br /> COMMENTS: <br /> Invoice#: <br /> phis ;Ca li iS no I rw i-Y) opwhon at �hi. ac1dNf, ftvu ed <br /> 1v IOP41 �-ti4 <br />