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Date run 11!7/2017 1:31:40PIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 11/7/2017 <br /> Record Selection Criteria: Facility ID FA0009358 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project speck,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. Ialso certify that all operations will be performed in accordance wfth all applicable Ordinance Codes andfor Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFEREDr, Amount Paid Date <br /> Payment Type Check Number Received <br /> El Staff: Date��/�/ Account out: Date <br /> COMMENTS: <br /> �, � A � 1 Invoice#: <br />