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Da%asa/run - °12/15/2011 8:58:13A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Page2 <br /> Facility Information as of 12/15!2011 <br /> jRecord Selection Criteria: Facility ID FA0000229 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,th derslgned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facilely or aaivily will be billed to the part3,de led as th ER on this formI also certify that all operations will be Performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws, <br /> APPLICANT'S SIGNATU Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to be T SFERED: Amount Paid - Date <br /> Payme yp Check Number Rec d by <br /> REHS. Date / lam/ Account out: Date I L / I /.�_ <br /> COMMENTS: . <br /> �a/moi <br /> i <br /> \\eh-env\envision\reports\5021.rpt <br /> i <br />