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SANJOAQUIN COUNTY RECEIVE® <br /> ' s> <br /> ENVIRONMENTAL HEALTH DEPARTMENTq ,� q0" Return this form by the <br /> L C <br /> 600 East Main Street:Stockton, CA 95202-3029 12 of each month <br /> ', - Telephone:(209)458-3420 Fax:{209) 464-0138 Web:wWw.sjgov.orglehd <br /> ENVIRONMENTALH <br /> j PT GE CLEANER'S REPORT HEALTH <br /> - ^ PERMIT/SERVICES <br /> Company Name: Yft ( D Report f onth of; NI�V year - <br /> am Company Address: __2q 7 7 7 <br /> sreNAdd:� - Signatu <br /> zc code —{ - <br /> Al <br /> m All information submitted must be tom fere. accurate. and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS ;R7 qes®ENILIL NAME OF TREATMENT <br /> N PUMPED PROPERTY OWNER PUMPED (G) CREASE 1wr <br /> PLEASE INCLUDE STgEEi t, DIRECTION, STREET NAME AND CITY G tHEMCAI ! FACILTY <br /> aiU <br /> City <br /> Ca __ <br /> C <br /> C' <br /> _ ci <br /> 0) C <br /> 001 <br /> Ci <br /> CMY <br /> 0 Ci <br /> X <br /> C <br /> LL <br /> C' <br /> U) Ci <br /> W <br /> U C <br /> W <br /> N <br /> LO CA <br /> C <br /> Ga Ci <br /> 0 <br /> O <br /> W G <br /> C <br /> Z <br /> O Cry <br /> W <br /> J <br /> CE E:0 4 44 / " <br /> •• 1014,177 ` EP <br /> Y TA <br /> J&F: � c�l ryJ c� �[� i'` V tai � CE l`LE.. S REPORT <br /> O U <br /> ch <br /> LL <br />