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EK�M <br /> 4/21/2017 8:18:40AII SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 4/21/2017 Page2 <br /> Selection Criteria: Facility ID FA0005626 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT Lthe Undersigned owner,operator or agent of same acknowledge that all ske,anryor project specific,PHSrEHO hourly charges associated with this facility <br /> or ectiviy 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 andror Standards and State andbr <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 k Number ReceiEHD Staff. <br /> ved by <br /> Date <br /> COMMENTS --q—/-2L/—i1— Account out: Date / <br /> COMMEN <br /> Invoice k <br />