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RECEIVE® <br /> ' SAN JQAQUfN COUNTY <br /> CD DEC .0 4 2014 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 12"'of each month <br /> w I Telephone.(209) 468-3420 Fax:(209)4640138 Web:mvw.sjgov.org/ehd <br /> 0 ENVIRONMEN I-LH Er1�T!i <br /> ,tea pERMITISFRVICES `� SEP"T-�AGE CLEANER'S REPORT <br /> Company Name: � li��D��� Report for tfie mo h of: /z�/ year <br /> Company Address. _ (, � �} �y>'� ��r.��o� �3(/ Signature: <br /> - — StreetAddress city Tie0,&j a <br /> All iniormatian submitted must be'com lete, accurate, and legible <br /> DATE NAME OF 13USINESS OR ADDRESS WHERE WORK WAS DONE GALLONS ( PEMDEATlAL NAME OF TREATMENT <br /> DIRECTION,�PUVPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET Y, DIRECTION, STREET NAME AND CITY C CHEM[GAL <br /> 1 <br /> r Citv <br /> w <br /> F- <br /> <I city <br /> { <br /> w <br /> F- city <br /> co <br /> <=I <br /> Ci <br /> co <br /> Ld <br /> city <br /> F <br /> <I <br /> City} <br /> city <br /> cit <br /> City <br /> rs, <br /> r� <br /> c <br /> l o <br /> C Ify <br /> � Q <br /> m cit <br /> Ln <br /> Ln <br /> v <br /> city <br /> com <br /> m city <br /> o <br /> � <br /> cC--4 <br /> CV <br /> city <br /> U <br /> N N <br /> city <br /> �. <br /> CD <br /> CV <br /> city -o <br /> QJ <br /> -. <br /> CN EFR7 42-D4 a' <br /> SEPTAGE CLEANERS REPORT <br /> 1-4 1aJ4ln7 a� <br /> ■ ■ ■ ■ 0 <br />