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Date run 1/24/2018 3:24:13PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 1/24/2018 <br /> Record Selection Criteria: Facility ID FA0004175 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project speck,PHSrEHO hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this tone. 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: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Teck Number Received by <br /> EHD Staff: _ Date / /20 Account out: > Date / J / jg <br /> COMMENTS: <br /> QD InV01Ce#: <br />