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Date mn 2/9/2011 2:32:08PM SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 15021 <br /> Page2 <br /> Run by 5290 " <br /> Facility Information as of 2/9/20'%/ <br /> Record Selection Criteria: Facility ID FA0009750 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project apedfic,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this roam. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number ,r ', Receiv/edby <br /> REHS: Date �l lLl� Account out: te <br /> COMMENTS: <br /> \\ehcnv\envision\reports\5021.rpt <br />