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RECEIVE® <br /> a•1 � 4� SAN JOAQUIN COUNTY <br /> JUL 15 2014 ENVIRONMENTAL HFALTH DEPARTMENT Return this form by the <br /> 1868 East Hatelfon Avenue, Stockton, CA 95205-6232 12t" of each month <br /> ENVIRONMENTAL HEA LTH Telephone., <br /> elphone:(209) 468-342D Fax:(209)464-0138 Web:x%wvw.sjgov,orgfehd <br /> PERMIT/SERVICES SEPTACE CLEANER'S REPORT <br /> Company Name: 9A A, Reportfor thm th of: year <br /> Company Address: 47� Signature: <br /> S1met Address C4 Zfp Cade <br /> All Information submitted must be corntete accurate, and legible <br /> DATE FLAME of BusitiEss OR ADDRESS WHERE WORK WAS DOME GALLONS (R) RESIDENUAL NAME OF TREATMENT <br /> PUMPED PROPERTYOINHER PUtJ1PIED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET 6 DIRECTION, STREET NAME AND CITY (C CNEhmm <br /> St <br /> 0 � �l U clly L d LA u <br /> 114l - Via via (r << <br /> ZeL C. 1City i'1'l c5 t <br /> �1 cl <br /> n L cit, <br /> `( t` <br /> c' I <br /> city <br /> cjty I <br /> cl <br /> - 1 <br /> CRYLSl <br /> city <br /> c� I <br /> Page of E� <br /> EIiD 42-04 SEPTATE CLEANERS REPORT <br /> 12127113 <br /> V <br /> N <br /> !lam <br /> ■ �■Il1 ll, 1111 <br />