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Date run 11/14/2008 7:47:56,4 SAN JOAOUIN COUNTY ENVIRONMENTAL HEALT" DEPARTMENT Report#5021 <br />Run by Paget <br />Facility Information as of 11/14/201._ <br />Record Selection Criteria: Facility ID FA0002836 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all 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 Ordlnace Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: " $20.00 = <br />Water System to be TRANSFERED: ' $372.00 = _ <br />Amount Paid <br />Amount Paid <br />Date <br />_ Date <br />Date <br />Payment Type Check Number P Receiv _ <br />REHS: Date �./ /4- <br />Account out: Date / <br />COMMENTS: <br />\\phs-ehsgI-nt\apps\envision s\reports\5021. rpt <br />