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Date run 10/17/2019 2:29:40F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#: <br /> Run by Page2 <br /> Facility Information as of 10/17/2019 <br /> Record Selection Criteria: Facility ID FA0013602 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project speck,PHS/EHD hourly charges associated with tl <br /> or activity will 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 StE <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 JCheck Number Received y <br /> EHD Staff: Date / 17/ 14! Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />