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Date run 4/8/2016 9:03:20AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 4/8/2016 Paget <br /> Record Selection Criteria: Facility ID FA0009522 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT, I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor protect speefic,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date _1_/ <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date-/-/ <br /> Water System to be TRANSFERED: Amount Paid Date 1 / <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />