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Date run 4/14/2Q21 8:39:09AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 4/14/2021 <br /> Record Selection Criteria: Facility ID FA0015392 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSIEHD hourly charges associated with this facility <br /> 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 Ordinance Codes andror Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 1L /)0 Date ! / <br /> 1-NProgram Records to be TRANSFERED: o'2 .400= 1 ab Amount Paid 00�00 Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type (�—Check Number es- Received <br /> EHD Staff: Date ! / Account out: Date / /'2Z <br /> COMMENTS: c� <br /> Invoice#: 3Jy)lsy <br /> RF�M�NT <br /> CE�V�� <br /> ,4PR <br /> 1y <br /> SAN✓0 ZD21 <br /> Ely AQUI <br /> H p P�� rY <br /> ENT <br />