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Date run _12/11/2012 8:35,50A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Page3 <br /> Facility Information as of 12/11/2012 <br /> Record Selection Criteria: Facility ID FAD003350 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly Merges associated with this facility <br /> or activity will be billed to the party identirrod as the OWNER on this font I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and Stale andfor <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 Typ / heck)Cumber Date 1�1 Account out: Received by ate <br /> REHS:� bI <br /> Q� <br /> COMME <br /> ,,frf7(1,4 T-E i!�-3 44WIe� OA-4r <br /> 56 <br /> WWI? <br /> DEC 11 212 <br /> ENPENM�MS HVA ESN <br />