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[Rehard <br /> ate ran 4/21/2017 8:18:40AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> un by <br /> Facility Information as of 4/21/2017 Page2 <br /> Selection Cdteda: Facility ID FA0005626 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anchor project specific,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identRed as the OWNER on this form. I also certify that all operations will be performed in accenuance with all applicable Ordinance Codes anclor Standards and State ancor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type ---� -Che cNumber Received by <br /> EHD Staff: Date, /—,2L/--L-J— Account out: Date l71 /�Z <br /> COMMENTS: <br /> Invoice$: <br />