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r�ul SAN JOAQUIN COUNTY <br /> a <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> _ 1868 East Hazelton Avenue, Stockton, CA 95206-6232 12tj' of each month <br /> Telephone:(209) 468-3420 Fax: (209)464-013B Web:wwmsjgov.org/ehd <br /> Y� SEP AGE CLEANER'S REPORT <br /> Company Mame: (� >/ <br /> Report forth m nth of: year fl�� <br /> Company Address: <br /> oZ�o Signature: <br /> Stree7 Aid ss CKY Vup Code <br /> All information submitted must be complete, accurate and le ible <br /> DATE NAME OF BU Sl NESS OR (R) RESIDEMIAL <br /> UMPED PROPERTY OWNER ON <br /> ADDRESS WHERE WORK WAS DOLE GALLS (G) cu>_AsE-r� NAME OF TREATMENT <br /> P <br /> PLEASE INCLUDE STREET x, DIRECTIOGPUIeON, STREET NAVE AND CITY (C) CFIEIAICAL FACiL <br /> MY <br /> yy} CI � <br /> r <br /> ^ � Citi Lt l (�Q �L <br /> City <br /> / ' L � <br /> CA <br /> CRY C-116 <br /> D m <br /> "[ C' t"l C4 <br /> 0 <br /> city <br /> J6 <br /> c• d <br /> -LI-1 <br /> M <br /> C 00 <br /> city SEP 10 2015 !� <br /> c31, EWRON 1T-At NMI Fj <br /> 0 <br /> city PERMIT(SERVICES <br /> cli,/ Q <br /> I <br /> c. <br /> E_ <br /> ---------------- <br /> c� <br /> Page of <br /> >Ho-42-04 <br /> 12/27/93 SEPTAGE CLEANERS REPORY <br /> d <br /> ■■ ■ <br />