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Date run 8/8/2009 9:47:02AM SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by, 406§ _ ' f � � Page2 , <br /> 1:�� Facility Information as of 618120 <br /> Record Selection Criteria: Facility ID FA0004"3 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project spec,PHSIEHD hourly charges associated with this <br /> facility or activity will 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 /> State andlor Federal Laws. <br /> Su, <br /> /�� I iii/APPLICANT'S SIGNATURE: / t-(R CµQ� _ Date �I o I r <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date Iir <br /> I <br /> Payment Type Check Number Received by <br /> REHS: Date 1 ! Account out: �z Date ! ! <br /> COMMENTS: <br /> a <br /> i. <br /> { <br /> E <br /> { <br /> 11eh-envlenvisionlreports15021.rpt <br />