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■iiii■ <br /> ECEIVE T <br /> ry <br /> SAN JOAQUIN COUNTY OCT 2 a 2014 <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 ENVIRONMEN!f,j. (each month N <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd PERMMSI <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: n6 ' S ids - 'P6xt/lcwel- Report for the month of: &1j/— _ year <br /> Company Address: l , 367 Signa <br /> Street Address City Zlp Code c. <br /> n <br /> ti <br /> cD <br /> All information submitted must be com Iota accurate and legible <br /> DATE NAME OF BUSINESS OR GALLONS (R) RESIDENTIAL <br /> ADDRESS WHERE WORK WAS DONE NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET DIRECTION STREET NAME AND CITY C CHEMICAL <br /> IN <br /> 60 i 0 y /7/D �igli� c; "':SG'le tet/ -70 '9'/ <br /> 00 <br /> • rar ��cY � Gtr�� Ivo <br /> GI <br /> city <br /> 0 <br /> CityV <br /> cityN <br /> CD_ <br /> city <br /> city <br /> cn <br /> crt <br /> Ci <br /> Cit J <br /> v <br /> v <br /> Cit <br /> v <br /> Page of <br /> CD <br /> 0 <br /> EHD 42-04 SEPTAGE CLEANERS REPORT p <br /> 1227113 0 <br />