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Date run 5/9/2017 12:59:40PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reportsi <br /> Run by <br /> Facility Information as of 5/9/2017 Paget <br /> Record Seticfion Criteria: Facility ID FA0009860 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party idents ied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ander <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 TyCheck Number Received �L <br /> EHD Staff: 1t,1 1Mjk, Date--5—/--9--/j-7— Account out: Date —5--1 O l 17 <br /> COMMENTS: <br /> A 1.� Invoice#: <br /> -Is ;Cu � IS no ) � r m oppwhm I 'at �U ac&/'ffl r1'l�/1.ctd <br /> nJ <br />