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r <br /> Date run 11/4/2015 10:45:17AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility information as of 11/4/2015 <br /> Record Selection Criteria: Facility ID FA0002715 <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 State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <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 ! 1 Account out: Date 1 I <br /> COMMENTS: <br /> Invoice#: <br />