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Date run 4/6/2018 4:18:21 PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />1 Run byl Paget <br />Facility Information as of 4/6/2018 <br />Record Selection Criteria: Facility ID FA0000356 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site, and/or 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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid <br />Water System to be TRANSFERED: <br />Payment Type Check Number _ <br />EHD Staff: �-�� fKf <br />COMMENTS: <br />Date <br />Amount Paid <br />Date <br />Date <br />Date <br />Received by <br />Account out: 16 Date / 7— <br />Invoice <br />Invoice #: <br />