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Dale hurt 1/19/2011 8:13:40AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL T <br /> Run by H DEYAR"I'MEN'1' new„^-�• <br /> Facility Information as of 1/1 9/2(,,w Paget <br /> Record Selection Criteria. Facility ID FA0006977 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hpudy charges associated with this <br /> facility of activity wilt 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 Ordmace Codes Indict-Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: K fit- 's � '� Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Eheck Number Race l y <br /> RENS: Date�_/ / _ Account out: _- Date /o _/�_ <br /> COMMENTS. <br /> \\eh-env\envision\reports\5021.rpt <br />