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Date run 5/4/2022 11:49:47AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Paget <br />Facility Information as of 5/4/2022 <br />Record Selection Criteria: Facility ID FA0001464 <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 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 and/or Standards and Stale andlor <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 bv <br />EHD Staff: Date / / Account out: Date fL/f`3/22— <br />COMMENTS: <br />Ir1V01Ce #: <br />Y\A5 LvGO✓�C�c V' A' <br />r V '� <br />