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Date run 3/9/2011 3:33:02PM SAN JOAOUIN COUNTY ENVIRONMENTAL HEAL TH DEPARTMENT Report#5021 <br /> Run by, 40T6 Paget <br /> Facility Information as of 3/9/20 <br /> Record Selection C.dteria: Facility ID FA0004909 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that ail site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. �t <br /> APPLICANT'S SIGNATURE: PO-R— L�-MoL —� A� ::rAZf4f1C Date -E? l lQ <br /> / it <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 /> REHS: Date / / Account out: Date / 10 <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />