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Date run 2/13/2017 1:06:31PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 2/13/2017 <br /> Record Selection Criteria: Facility ID FA0009333 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowletlge that all site,andfor project specRc,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as Me OWNER on this fort¢ Ialso 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 I_I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / /_ Account out: J— Date <br /> COMMENTS: <br /> Invoice* <br />