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Date run 2/11/2015 2:49:501 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 2/11/2015 <br /> Record Selection Criteria: Facility ID FA0003671 <br /> Sit-LING 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 INs 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 and/or <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date / J <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment T Check Number Received by. <br /> REHS: Date / / Account out: Date 1)'Zt- )) / S <br /> COMMENTS: <br />