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Date run 12/27/2011 1:32:41 F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 12/27/2011 Page2 <br /> Record Selection Criteria: Facility ID FA0018043 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this <br /> i facility of activity Witt be billed to thepar.ty identified as the OWNER on this form. 1 also certify that all operations will he performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> IF State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE:/\\\ Dater 1 1 <br /> Program Records to be TRA <br /> NSFERED "$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date ! 1 <br /> Payment T Check Number Received by <br /> REHS:C Dat �? _/C5�� //� Account out: Date 1 ! <br /> COMMENTS: <br /> i <br /> i <br /> i <br /> i <br /> J <br /> Ileh-envlenvisionlreports15021.rpt I' <br />