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Report fR5021 <br /> Date mn . 5/24/2017 4:27:45PIv SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Rege2 <br /> FRun by Facility Information as of 5/24/2017 <br /> Record Selection Chrome: Fadllty ID FA0003757 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT 1,the undersigned owner,operator or agent of same,acknowledge that all site,andor project sPablc. HSEHDOrdinance <br /> 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 accordanrs 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, I 1 <br /> EHD Stafr. M9SEC-h L A4N--a Date�_/ ZS /�_ Account out: <br /> COMMENTS: Invoice#: <br />