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Date run 3/23/2022 11:45:20AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report $5021 <br />Run by Paget <br />Facility Information as of 3/23/2022 <br />Record Selection Criteria Facility ID FAD004443 <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 facility <br />or activdy will be billed to the parry Identified as the OWNER on this lam 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 J ! Z + / Z2- <br />Program <br />LProgram Records to be TRANSFERED ' $25.00 = Amount Paid Date / / <br />Water System to be TRANSFERED: Amount Paid Date / / <br />Payment Typef Check Number Received by <br />EHD Staff: Y!� : L� ,`S (o �.. c, c. ; „ rDate I ccount out: Date <br />COMMENTS: <br />Invoice # <br />e311y �'�,°ca�,B�v, ,n,f� ,�. ,, ,L.�Io>1 ��fel oY�,..'y,� a %� <br />