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RECEIVED <br /> MAR 2 4 2015 <br /> SAN JOAQUIN COUNTY <br /> O ENVIRONMENTAL HEALTH DEPARTMENTeturn this form by the <br /> NVtppNN(EN7At_H <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 T7RM1T1SERV1C S12m of each month <br /> Telephone:(20� 468-3420 Fax:(209)4640138 Web:www.s�gov.org/ehd <br /> 07 / M <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name; ''-+E- 1='A4Af CRI Report for the month of: year <br /> CD <br /> Company Address: S `v �� C+4 �6� Signature: <br /> StreeAddress City Zip Code <br /> All Information submitted must le complete, accuralE and legible <br /> CD <br /> N DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> A9DP,ESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> N PLEASE INCLUDE SI-R-EET M DIRECTION STREET NAME AND CITY C CHEMICAL <br /> Cl) <br /> O <br /> Cfty <br /> city <br /> (�G <br /> city <br /> city <br /> rn <br /> rn <br /> cm city <br /> � <br /> cirty <br /> rn <br /> c� CC> <br /> City m <br /> m <br /> ,�.�� city <br /> o <br /> U c <br /> cityO <br /> � CI <br /> U L� <br /> > <br /> cityo <br /> a� c� <br /> cn city <br /> � C � <br /> a <br /> i3 <br /> � C' <br /> 0- a <br /> C <br /> city <br /> Y Page of > <br /> ESEPTAGE CLEANERS REPORT <br /> LL <br /> 12/12711327113 <br /> ■ ■ ■ ■ 0 <br />