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Dale nm 4/282017 2:58:05Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P <br /> Run by Report <br /> Facility Information as of 4/28/2017 Page2 <br /> Record Selection Galeria: Facility ID FA0009619 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,andf r project specific,PHSEHD 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 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 b <br /> EHD Staff: Date Account out: Date_4_1 /� <br /> COMMENTS: <br /> Invoice* <br />