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Daterun 2/7/2022 2:11:23PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 2/7/2022 <br /> Record Selection Criteria: Facility ID FA0012769 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclior 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 anctor Standards and State ancilor <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 by <br /> EHD Staff: Date / / Account out: Date owl / :t� <br /> COMMENTS: <br /> Invoice#: <br />