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tReport#5021 <br /> Date run 10/19/2016 2:22:08F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Paget <br /> Run by Facility Information as of 10/19/2016 <br /> Record Selection Criteria: Facility ID FA0009750 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,aclorm tlge that all site,andor project specific,PHSUEHD hourly charges associated with this facility <br /> oractwity will be billed to the party identified as the OWNER on Nis form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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: Invoice#: <br />