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�0.51'. ..f?p'. <br /> m fLi,P, _ 2ii SAN JOAOUIN COUNTY RECEIVED <br /> ED <br /> .� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Slreet, Stockton, CA 95202-3029 APR 1 1 2012 12d1 of each n thisn this fmon orm borm y the <br /> a •� . Telephone:(209)466.342D Fax:(209) -0136 Web:www.sjgov. <br /> 464 org/ehd <br /> SEPTAGE CLEANER'S REPORT ENVIRONMENTAL HEALTH <br /> Company Name: gQ PERMIT/SERVICES <br /> Company Address: Q. (� , C�iG x cl H��� Q Report for the month of:� year <br /> ao,AdcRa 50.G �_ <br /> �P CRee h1ia nn <br /> - <br /> All Inform4 Signature:_ <br /> cubmitt¢d must be com Tete accurate, end le Ible <br /> DATE NANO OF SIUSINESSOWNER <br /> OR ADDRESS WHERE WORK WAS DONE (R) nesmEtuTutL <br /> = PUMPED PROPERTY OWNER GALLONS NAME OF iREATY1ENi <br /> f- <br /> PLEASEINCLUDE STREET A, DIRECTION, STREET NAME AND CITY PUMPED (Ol GREASE TRAT FACILITY <br /> 4 C LNEMCAL <br /> J� Ch <br /> Cd <br /> C' <br /> w <br /> L <br /> C <br /> C' <br /> C <br /> C <br /> LLJ <br /> CM1 <br /> m C <br /> m <br /> m <br /> v <br /> o c <br /> PI <br /> m <br /> N C <br /> C <br /> N <br /> N <br /> C <br /> T <br /> D <br /> ti <br /> D Le <br /> V <br /> n C <br /> V <br /> EMD 12 <br /> '""°' No Ing oLS Ser, pc L vr� pe <br /> SEPTAGE C{EA4ER5 REPORT <br /> -COr d he rn Y) t o� March 0 1ES , <br />