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•.i t <br /> Date run '51412017 3:31:37PM SAN JOAQUI.N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> .. i Paget. <br /> Run by <br /> Facility Information as of 5141201.7 <br /> Record Selection Criteria: Facility ID FA0020304 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHSlEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this fear I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State and'or <br /> Federal Laws- '1 - - <br />} <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amotiht Paid Date 1 1 <br /> Payment Type�' Check Number Received u) <br /> EHD S! . .Date 5 1_�1 a Account out: /�C - Date a 1 _I 7 <br /> COMMENTS: .. Invoice#: <br /> [i <br /> 4 <br /> r <br />€ 't <br /> l <br /> i <br />{ r <br /> 1` <br />