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Date run 10/11/2018 11:03:08,4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 10/11/2018 <br /> Record Selection Criteria: Facility ID FA0010282 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSrEHD 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 andror Standards and State andtor <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 /> EHDStaff: (Self 1?e.'l/cRt'cchina. Date d / I / /(F_ Accountout: Date <br /> COMMENTS: <br /> Invoice#: <br /> P,`Jr�cV0 Coc]P X783, �?eC-C�S 'fJ be Cl�tsn�eC, �o d 831. File i fev�tove <br /> j f.•1 one to 0 <br /> W�iG� ��iY1G5 t�1C;vt l_',��YZ +00" laweK t►ef. 13ri.Sc°C� on STC <br /> J �°l�►lig <br />