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Date run 11/3/2016 8:14:42AIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 11/3/2016 <br /> Record Selection Criteria: Facility ID FA0000380 <br /> BILLING and COMPLIANCE ACKNOVA-EDGEMENT: I,the undersigned owner,operator or agent of same,ack,bwledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be WHO to the party identified as the OWNER on this form. I also ceddy that all operations will be performed in accordance with all applicable Ordinance Cortes andor Standards and State andor <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 Tyq� Check Number Received <br /> EHD Staff: LSI17v Date I /� Account out: Date1 / /_Z�- <br /> COMMENTS: <br /> Invoice#: <br />