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Date run 6/17/2011 2:05:11 Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pag82 <br />Facility.lnformation as of 6/17/2011 <br />Record Selection Criteria: Facility lD FA0000187 <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same. acknowledge that all site, andfor project specific, PHSIEHD hourly charges associated with this <br />facility 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 Ordinate Codes andfor Standards and <br />State and/or Federal laws. <br />APPLICANT'S SIGNATURE: Date 1 1 <br />Program Records to be TRANSFERED: " $25.00 = Amount Paid Date / 1 <br />Water System to be TRANSFERED: Amount Paid ate 1 I <br />Payment Type Check NumberRecei y <br />RENS: i Ian DateAccount out: pA Date <br />COMMENTS: <br />0"e, Pu aa4-1 � _vl5cb <br />\\eh-envlenvision\reportsk5021.rpt 0 46 <br />