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Data run 8/23/2017 9:46:47AR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reportse021 <br /> Run by <br /> Facility Information as of 8/23/2017 Page2 <br /> Record Selection Criteria: Facility ID FA0012437 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Ne undersigned owner,operator or agent of same,acknowledge Nat all site,andor project speci(c,PHSrEHD hourly charges associated with this facility or: <br /> be billed to Ne party Identified as Ne OWNER on this forth 18150 certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor 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 Check Number Received by <br /> EHD Staff: Date / / Account out: Date_�/ l.3 /f <br /> COMMENTS: 41 <br /> Invoice#: <br /> /�a, ��NcJ w�c.(ress c�ArSccP as ner— <br /> Ccs L\ <br />