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Date ren 12/8/2017 1:06:02Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 12/8/2017 <br /> Record Selection Criteria: Facility ID FA0007695 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andcr project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identfed as the OWNER on thisform l also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Statmards and StateancVor <br /> Federal Laws, <br /> APPLICANTS 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 by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice* <br />