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RECEIVED <br /> D ° � <br /> MAS` lb l- 2016 SAN JOAQU[N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMERT Return this form,by the <br /> w600 H 600 East Main Streef, Stockton, CA 95202-3029 12th of each month <br /> \ EAt Uephone:(2D9)468-3420 Fax; (209)464-0138 Web:www.sjgov.org/ehd <br /> PERMIT/SERVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company Marne. Yl -� G � C <br /> Report for the month of P p� year <br /> Company Address: If'_,5�2 r`0 x Dq �l<�� �Z536 � Signature: -- <br /> Street Addcew City Zip Coda <br /> Alf i,nformatlon $ubmittsd must be'com lete, accurate, and legible <br /> DATE NAME OF BUSiHESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) aEsiD�malOF <br /> YlfdPED FACILITY <br /> PROPERTY OWNER PUMPED (G) GREASEnW NAME FLITY TREATMENT <br /> PLEASE INCLUDE STREET r, DtRECTi01(, STREET NAME AND CITY C CRUI-AL <br /> LLLJ <br /> c{ C, <br /> W <br /> f— <br /> UL C rty <br /> _< <br /> (n Cit <br /> W <br /> I— c. <br /> <-L <br /> Cm <br /> - aU <br /> C <br /> Ci <br /> JC4 <br /> o <br /> l ` z <br /> Cit <br /> v <br /> 7t <br /> � <br /> GN <br /> •- <br /> v a 1 <br /> OD <br /> �D I <br /> N <br /> c" <br /> city <br /> N -- <br /> �D <br /> m <br /> N <br /> � <br /> City <br /> m 1— <br /> C14 <br /> city <br /> -a <br /> N v <br /> 0 HD 42-04 SEPTAGE CLEAVERS REPORT <br /> 1141,17 <br />■ ■ ■ ■ ■ <br /> ■ ■ ■ ■ ■ <br />