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Dale No 1/6/2012 4:18:17PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repo"#5021 <br /> Run by Page3 <br /> i Facility Information as of 1l6I2012 <br /> Record Selection Crltena: Facility ID FAD003350 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,all project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed!to the party identified as the OWNER on this fano. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or 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 Date <br /> Payment Type Check Number Received by <br /> REHS: Date_/ / Account out: Dated_/��! 2 <br /> COMMENTS: <br /> \\eh- nv\envision\reports\5021.rpt <br />