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RECEIVED <br /> uIri% FEB Q � 20i� SAN.1aaaUI�1 COUNTY Return this form by the <br /> ENVIROMMENTAL HEALTH DEPARTMENT <br /> ENVIRONMENTAL 1868 East Hazelton Avenue, Stockton,CA 95205-6232 12"' of each month <br /> ` HEALTH Telephone: (209)46B-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PERMIT/SERVICES <br /> SEPT E CLEANER'S REPORT <br /> Company Name: <br /> { Report for th m6nth of: year <br /> Company Address: Signature <br /> Stree dress . Zip Code <br /> AH information submitted must be com tete, accurate, and le fble <br /> DATE NAME OF BUS]4ESS OR ADDRESS WHERE WORK WAS DOME (R} NAME OF TREATMENT <br /> RES[uE - At <br /> GALLONS <br /> PUMPED PROPERTY OWNER PUMPED CG} cl�AseTRnv FACILITY <br /> PLEASE INCLUDE STREET @, DI ECTION, STREET NAME AND CITY tGl CHEWCAL <br /> gb <br /> —� �l tr ct ct <br /> } C G <br /> /S S <br /> ,2� r <br /> CM- <br /> City ce 1 r <br /> � <br /> l cel � <br /> Ulf6 u cl <br /> cito <br /> m <br /> c1tv <br /> z <br /> �G 1 C [I 5' <br /> C' ar 4 <br /> 0 <br /> CK <br /> l <br /> c <br /> city <br /> LL <br /> {i, s <br /> Page of <br /> --a <br /> EHD 42-D4 <br /> SEPTAGE CLEANERS REPOP.T <br /> u <br /> 1212711.3 a' <br /> M m■ N■■ <br />