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DatrPrun 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, andror 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 andror Standards and State andlor <br />Federal Laws. <br />APPLICANTS SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />Date <br />* $25.00 = Amount Paid Date / ! <br />Amount Paid Date <br />Received by <br />Date / / Account out: Date <br />Invoice #: <br />