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Date run 1/11/2016 8:28:41 AA SAN JOIN COUNTY ENVIRONMENTAL HEA Report#5021 <br /> DEPARTMENT page2 <br /> Run by <br /> Facility Information as of 1/11/2016 <br /> Record Selection Criers: Facility ID FA0010287 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project speck,PHSrEHD hourly charges associated with this facility <br /> or adiyitywill be billed to the party identrfied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andbr Standards and State ander <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: <br /> Invoice#: <br />