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RECEIVED <br /> N <br /> C <br /> C: aT�° SAN JOAQUIN COUNTY <br /> y�, ENVIRONMENTAL.HEALTH,DEPARTMENT AUG $ 2014 Return this form by the <br /> 186$.East Hazelton:Avenue,:Stockton, QA 95205-6232 12t" of each month <br /> ` Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.IsR VIAL HEA(-TFC <br /> SEPTAGE CLEANER'S REPORTPERMIT/SERVICES <br /> rr11 <br /> Company Name: t� d my'([ L)� Report for the:month of: t year <br /> a <br /> CompanyAddre$s: LA�t ;y <� � try. q1f �sf c��� ��+�r�" Signature: t-- <br /> Street Address I City Zip Code <br /> All Information submitted must becomplete, accurate and legible <br /> DATE NAME OF Sl1SINE$S OR ADDRESS WHERE WORK WAS DONE GALLONS {�1 RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PLEASE IN C L U D E S T R E ET #, DIRECTION, STREET NAME A.N D CITY PUMPED ��') GREASE TRAP FACILITY <br /> �) .11,,�.-,, yy p }/�yy. /.� f C CHEMICAL <br /> i 1 I �r�4d'. I.d/Vff,1., s,�' �c vi'VU i i"�'r ,r, '' trJ city- 1"Yld !'{�- --- /�� <br /> J' �W I.4 4Vf'�l Ct-� r `"-r.1- 5-7� I rid 1 e 61�F�' city /�'�•-t,.�. (JC:J 1 e. <br /> 1 s0.�,� <br /> S 114U>2F46 m ttr L&*ry 4 61ty IND <br /> W ,?-Wo,?-W Nlermas, ? q6su"tlel ftae.1 city fY li <br /> o _ . <br /> NI 1 V f t 5[ 'I e7�'J t /GCS <br /> -57 <br /> tom` �F <br /> oC : vv( P0 - <br /> Ci b 30 Iast�� c �i� �_ �� ��.� V��+e•_ opo <br /> N <br /> Cify <br /> [7 <br /> ci .m' `.j(mac' W Q� <br /> p I '�I�inl {c t iiu bz. s c YYk4— j-4L <br /> 1/1414 city <br /> `Z ON ` mrt.. o <br /> '71161/ VMA ZJ-A, br^u5.WW,1 11 On) L-. ROY 1• i <br /> city '2m) <br /> citye <br /> o <br /> N � <br /> CU SEPTAGE 42=04 SEPTAGE CLEANERS REPORT a' <br /> IL 10/4/07 c� <br /> a� <br /> 0 <br />