Laserfiche WebLink
Date run 12/30/2015 1:57:17F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Page2 <br />Facility Information as of 12/30/2015 <br />Record Selection Criteria: Facility ID FA0010390 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor project specific, PHS/EHD 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 andror <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 by <br />EHD Staff: Date ('2 / -?C l OW; Account out: Date <br />COMMENTS: <br />Invoice #: <br />-IeIGI(�jc�fl°� d�'L <br />�l Vb <br />