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Date run 7/2212013 2:56:44PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Rur,by ` Page3 <br /> Facility Information as of 7/22/2013 <br /> Record Selection Criteria: Facility ID FA0003350 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER on this fomt I also certity that all operations will be performed 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 Date <br /> Payment Type Check Number Recei <br /> REHS: Date / /_ Account out: Date / /L <br /> COMMENTS: <br />