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CD <br /> RECEIVED <br /> CD ; SAN JOAQUIN COUNTY <br /> a z ENVIRONMENTAL HEALTH DEPARTMENT NOV 14 201A Return this form by the <br /> Ln 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12"'of each month <br /> co <br /> C\jj telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov._ <br /> _ NMENTAL HET. <br /> PERMIT/SERVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name. n ►,�S C&r Report for the month of: OGS�� year ~ <br /> o Company Address: 3 Signature: <br /> Street Address City Zip Code <br /> v <br /> CD All information submitted must be complete, accurate and legible <br /> N <br /> v 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 M DIRECTION, STREET HANE AND CITY C CHEMICAL <br /> city <br /> 0 ' S city <br /> city <br /> ..+ -T,7 LA,f CK <br /> 07 -- <br /> co 00 <br /> M <br /> city <br /> C7 <br /> city <br /> r` <br /> _ � <br /> cfl � <br /> co Cit ~ <br /> Uw Lk <br /> 0 <br /> z <br /> Cit <br /> city C� <br /> CA/ CRY <br /> U <br /> _ <br /> city �r <br /> G <br /> CitCIO <br /> CV <br /> Cr <br /> Cit o <br /> { Z <br /> city <br /> N ;= <br /> 4, <br /> -9-- city <br /> a1 Page of <br /> c <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/17/13 an <br /> t1 � <br />