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RECEIVE® <br /> h . SAN JOAQUIN COUNTY <br /> APR 10 2014 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> hone; (209) 468-3420 Fax; (209) 464-0138 Web:www.sjgov.org/ehd <br /> EPMRONMENTAL HEAL�1 <br /> PERMIT/SERVICES SEPTAGE CLEANER'S REPORT <br /> Company Name: F/ CQ M 1 yu n 1I) o CLi-- (' _ Report for the month of; J� C C year <br /> Company Address: r���0, 8na', 1�3 ScK C'. G Q Ll Lk Signature: �� ) C` , <br /> Slreot Address city Zip Code <br /> All Information submitted must be comp-Iota, accurate and le able <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUdE STREET 0, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> city W)OLc 5 C To(ver Rk t <br /> Cit <br /> Cit <br /> Cit <br /> Clt <br /> Cil <br /> Cit <br /> Cit <br /> cit <br /> CII <br /> cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cil <br /> Cit <br /> Cil <br /> CII <br /> EHD A2-t7d <br /> 10I4/07 SEPTAGE CLEANERS REPORT <br />