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Date run 12/30/2009 12:00:141 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by g <br /> Facility Information aS Of 12/30/201 Pa ez <br /> Record Selection Criteria: '`Facility ID FA0000903 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or prefect specific,PHS/EHD hourly charges associated with this <br /> facility or activityw-ill 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 Ordinate Codes and/or Standards and <br /> Slate and/or Fe&4 Laws, <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> F <br /> i Program Records to be TRANSFERED: "$20.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date / / s <br /> PaymentCheck Number Received by ' <br /> J REHS:'/��j _ Date / 1 G I Zc:> Account out; Date 1 1 f <br /> { COMMENTS/- <br /> `-.S7C.�' ren!'-!1-0/ C LO�✓G�-"�. /.c/.�G�+Si '- .� '-��?�•��� <br /> �, 7�a� >�Y rs,� crr?y-�S�.�.7�✓„ ��o lei - t <br /> I <br /> i <br /> 1 <br /> 1 <br /> f <br /> i <br /> I <br /> I <br /> f <br /> t <br /> I � <br /> I 1 <br /> lheh-envlenvisionlreports15021rPt <br /> i <br /> M <br />