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Date run 12/27/2017 8:32:04A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by DONNA Page2 <br /> I <br /> Facility Information as of 12/27/2017 <br /> Record Selection Critena: Facility 10 FA0004959 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also panty that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Lewis. <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 .—/l Check Number Received by <br /> EHD Staff: --IIS ( _ .� L Date <br /> 1L—LZ-7 /—L2-- Account out: Date <br /> COMMENTS: 7 J <br /> Invoice#: <br />