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SAN JOAQUIN COUNTY <br /> a ENViRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avef1U�, Stockton, CA 95205.6232 12t" of each month <br /> Telephone:(209) 46B-3420 Fax:(209)464-0138 Web:www.sjgoie.org/ehd <br /> S TAGE CLEANER'S REPORT r <br /> Company Name: Report for th b th of- 1 year <br /> Company Address: <br /> Signature• <br /> City Zip Code <br /> All intormation submitted must be com tete, accurate and legible <br /> DATE NARAE OF BUSINESS OR ADDRESS WHEREYJORK'WAS DOME GALLONS �R) RES DEi1T1A1 tE OF TREATMENT <br /> PUMPED PROPERTY OININER (R) GR SETR0.P NAt4, <br /> PLEA.SE. lI1CLU0E STP.E�T k, DIRECTIog. STREET NAME AND CITY PUMPED (C) CHWCAL FACIL{TY <br /> Cityo <br /> Crly a' <br /> ^ S� <br /> v Cit <br /> �J <br /> � <br /> / f o <br /> [� ca <br /> I <br /> 0 <br /> i <br /> CRY <br /> Q <br /> City <br /> RECaVEDE. <br /> c� <br /> SEP 0 7 2W <br /> C <br /> C I <br /> Page of <br /> EHD 42-04 ,�MP ALW-3131 <br /> 12127/13 <br /> 'i4k PEWffX&WCE9 SE?TAGE OLEANI=RS REPORT <br /> W%%MM. <br />