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Data ran 17/29/2018 4:20:42P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report 15021 <br /> Facility Information as of 11/29/2016 Paget <br /> Record Selection Cnteria: Facility ID FA0003284 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all Site,and'or project specific,PH&EHO hourly charges associated with this facility <br /> or activity will be billed!to the party identified as the OWNER on this form I also coolly that all operations will be perforated in accordance with all applicable Ordinance Codes andor Standards and State and'or <br /> Federal Laws <br /> APPLICANT'S 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 Check Number Received by <br /> EHD Staff: Date_/ / Account out: Date <br /> COMMENTS: <br /> Invoice* <br />