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Dale run 2/13/2017 1:06 31 Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Runt,.y Paget <br /> Facility Information as of 2/13/2017 <br /> Record Selection Criteria: Facility ID FA0009333 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with Nis 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 perfomed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice i!f: <br />