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>ar" ti DECEIVED SAN JOAQUIN COUNTY <br /> . N 1 Z 20�$ ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12 of each month <br /> ENVIRONMENTAL HEAZ llephone:(209)468-3420 Fax.{209}464-0138 Web:wvm.sjgov.oTglehd <br /> PERMIPSERVICES SE TAGE CLEANER'S REPORT / <br /> Company Name: 4Report for the mon of: <br /> Company Address: (Signature: , <br /> SUeet Addref&s Tip Cask_ <br /> All information submitted must be complete, accurate, and le Ible <br /> DATE NATAE OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDEtiitA.L NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUIdPi=D (G) cREASETRAP FACILITY <br /> PLEASE 1VCLUDE STREET A', DIRECTION, STREET NAME AND CITY C) CREPKICAL <br /> cit t <br /> LL <br /> �� ISIE , a0 L( ( L( 1c <br /> r- j cit, <br /> u <br /> I ' 6 E hl--\ <br /> f2 !� L b cit C/Y L C v O <br /> CRY <br /> \ r L c <br /> o <br /> � <br /> C- ( z <br /> c: <br /> I <br /> CRY <DC) <br /> 0 <br /> City <br /> city <br /> City � <br /> l <br /> C. N <br /> E_ <br /> city ~ <br /> Page of <br /> N <br /> EJID 42-04 SEPTAGE CLEANERS REPORT _ <br /> 12127/13 <br />