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Date ruit 2/25/2016 10:24:26AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by <br />Paget <br />Facility Information as of 2/25/2016 <br />Record Selection Criteria: Facility ID FA0003919 <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 andlor Standards and State andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE <br />Program Records to be TRANSFERED: * $25.00 = <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: Date <br />COMMENTS: <br />Date <br />Amount Paid Date <br />_ Amount Paid Date <br />Received by <br />411 Account out: V5 Date —IT—' <br />Invoice #: <br />\\J�- t l -)e-- CW 2 0/ 6 --(-5 <br />r <br />ir,S,� Zi y <br />