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Date run 1/14/2022 2:02:32PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 1/14/2022 <br /> Record Selection Criteria: Facility ID FA0010514 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same.acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form.I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Typpee,11// Check Number Received <br /> EHD Staff: �Yr� C�o� Date 1 /14 /22 Account out: Date 2/ / 2—2 <br /> COMMENTS: Invoice#: 3 6 J V 1 <br />