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Date run 8/25/2015 11:51:41AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Faun by Paget <br />Facility Information as of 8/25/2015 <br />Record Selection Criteria: Facility ID FA0003677 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor project specific, 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 andlor Standards and State andtor <br />Federal Laws. C <br />APPLICANT'S SIGNATURE: i �1n VT Date G) /2 <br />Program Records to be TRANSFEF� l D a �(3 * $25.00 = 71mount • wrt"APaid J/ Date / 015/ <br />Water System to be TRANSFERE�a Amount Paid Date <br />Payment Type % heck Numbe(n-►F,-Z�K 00 , / -6 Received by lY\ <br />EHD Staff: W d t- v Date / q Account out: r Date <br />COMMENTS: <br />Invoice #: <br />