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RECEIVEDSAN JOAQUIN COUNTY <br /> OCT 08 2013ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 12'h of each month <br /> A ENVIRONMENTAL HEALTH <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd PERMISEPTAGE CLEANER'S REPORT <br /> T/� CES <br /> Company Name: Report for them th of: S <br /> year�4/3 <br /> Company Address: Signature: <br /> Street Address C4 ap Code <br /> [o -- <br /> All information submitted must be complete, accurate, and legible <br /> I` DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET R, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> `7 <br /> i <br /> p C <br /> city <br /> city <br /> C <br /> city <br /> city <br /> citf <br /> city <br /> �o <br /> cr <br /> UZY -- <br /> 1 <br /> 0 <br /> cityz <br /> CRY o. <br /> m <br /> CRY C-4 <br /> C' m <br /> 0 <br /> r <br /> ritu <br /> U � <br /> city <br /> CE C <br /> U <br /> IT) V O <br /> C Q <br /> city <br /> I - <br /> ri <br /> 0 <br /> EHC 42-04 > <br /> OJ 1014107 <br /> SEPTAGE CLEANERS REPORT <br /> i <br /> a' <br /> i l <br />