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Del. ran 524/201610:55:12A1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R.,N$ WI <br />Run M Paae2 <br />Facility Information as of 5/2412016 <br />Ramn]Sebnbn Cmvb: FWIAY ID FAOD03761 <br />BILLING and COMPLMNCE ACM0WLE0GEMERT: I, Ne vtlertlgned vane, apelelor a edail of tame, atlalowadpe IM1v al sde, aMbf pNte[I epedd4 PHS�EHD Inaly Aurya[ assaaeled Mtn IN[ Iemty <br />IX ecuWry wll be Nlad to Jn pally itlendded ea Uu OWNER m dJs form I a4o WIty dul ap openums wD M padomrod In awdenu w1N ell eppL®eta Oldnanrn Codes anoor $bMeNs vid Slala endor <br />Fedofal <br />APPLICANTS SIGNATURE: �lM�/`h,-.�^ Ul OL' Date <br />Program Records to be TRANSFERED: 5.00= Am ual Paid Dale_/_! <br />Water System to be TRANSFERED: Amount Paid Date_/_ <br />Payment Type Check Number Recelved 1hr <br />EHD Stag: �— Date /—Ll Account out: <br />COMMENTS: Im oice a{' <br />