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Dale run 1/2!2020 11A9:59AN SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTII DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 1/2/2020 Paget <br /> Record Selection Criteria: Facility ID FA0000131 , <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same acknowledge that all site anryor protect spec,fic.PHSrEHD hourly charges associated with this facility <br /> or activity vnll be billed to the party identified as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and(or Standards and State and for , <br /> Federal Laws l <br /> i <br /> APPLICANT'S SIGNATURE:. Date <br /> Program Records to be TRANSFERED '$25.00= Amount Paid Date <br /> Water System to be RANSFERED: I <br /> Amount P Date / <br /> Payment Type Check Number Received <br /> EHDStaff: Date / / Account out: Date_L/ / <br /> COMMENTS: <br /> Invoice#: <br /> tiFy0 <br /> 611"O Q� q-0?l�C� ,N�tiopRF ��2-y <br />