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Date run 12!28/201.2 9:11:17A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reportasozf <br /> Run by - Page2 <br /> Facility Information as of 12/28/2012 <br /> Record Selection Criteria: Facility ID FA0006832 <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 identified as the OWNER on this form I also certify that at operations will be pedormed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 Dale <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: ate ?—f z / <br /> COMMENTS' <br />