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■ ■ ■ ■ ■ <br /> ■iiii■ <br /> RECEIVED <br /> IRI p�� 2��6 SAN JOAQUIN COUNTY <br /> 1 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> ENVIRONMENTAL H1868 East Hazelton Avenue,Stockton, CA 95205-6232 121' of each month <br /> PERMIT/SERVICES Aphone: (209)468-3420 Fax:(249)464-013 B Web:Nvu�rv.sjgov.orglehd <br /> EPTAGE CLEANER'S REPORT <br /> Company Name: GReport for the mo of: ear ;LO <br /> v, Company Address: 2')- Signature: <br /> tistreet Address city 2=p Code <br /> 0 <br /> All information submitted must be complete, accurate, and le Ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESNENML NAME OF TRE=ATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GRF115ETRAP FAC[LITY <br /> 0 <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET }DAME AND CITY C) CRENCAl <br /> L Y <br /> 0 <br /> LR V t l LL `t <br /> cn <br /> 34 0 u <br /> 7 <br /> L <br /> 07-24 Mn1 CityL cE <br /> 73 Gtty <br /> u <br /> city <br /> L " X3 pf I-L <br /> e 4Su, city ! <br /> 1 �i ci <br /> l �it <br /> city I-C <br /> Y a r Cit <br /> 1 Cii•1 <br /> _ c, ti <br /> city <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS RF30RT <br /> 12/27/13 <br />