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vow <br /> wDater& � 8/16/2022 9:44:34AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 8/16/2022 <br /> Record Selection Criteria: Facility ID FA0003345 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: [,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S 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 b <br /> EHD Staff: (1n., r,rr t h Ea - Date- 8' /_14 01.7 Account out: Date <br /> COMMENTS: <br /> - pEZ O'PEiZATOTZ l-IE 1S NO LONCat1Z i Invoice#: <br /> � N Tl-1E Db.1r2�/ BU�SINEJ� . <br />