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Date run , 12/18/2012 11:57:07/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Page3 <br /> Facility Information as of 12/18/2012 <br /> Record Selection Criteria: Facility ID FA0003350 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andifor project specific PHSIEHD hourly charges associated with this facility <br /> or sctivity will be billed to the party identified as the OWNER on this font I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S 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 /> REHS Date Account out: Date / / <br /> COMMENTS: <br /> .A j <br /> 1 / <br /> �llL��jL er#c�tio� ''// <br />