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QtJ1N COUNTY' <br /> Y 4� LNVaRE)NMENTAi.:HEALTN DEPARTMENT <br /> 1868East Hazelton Avenue;Stork n;GA 952D5 $2 2. R+�u rn this form by fhe, <br /> Telepholre:(249}46r3 3420 Fax {209}4fid-093.8 Web.www.sjgov.org/eh:d �� of each mtlth <br /> 1= �RL's Ft �r <br /> SEf�TAGE C .EANER`S REPORT <br /> Company lyarn+e: f1 '1 t' <br /> Re <br /> Cr�mpar�y"Add�re$s: ,. (; ,. Port Farthe month of- , <br /> ( yeas'' <br /> StreeiAdcires C.ityt.' Sigma#ure:, ' <br /> 77..^^( e .li ter? <br /> " Y code 1 <br /> All <br /> Information sratarnitled must be com laic; aCturate Arid to ihle <br /> DATE NAND OF BUSINESS oft, ADDRE5's W11 RE WORK WA5 DONS IR}..RESFbENnni <br /> PUMIyt 0 PROPERTY OWNER GAL EONS <br /> PLE.A$E r1+tCLUgESTREEF. B, pIRICTiON;, $IRE ET' 'AIVEAN4 .CITY' AMi��TRINAA �T1T' <br /> PiIMPED (0 GREASE TRAP <br /> � ti, { FACILITY,. <br /> T`�' �`��,�,,�, C' GEIEtiAtCAL <br /> nit <br /> cif <br /> t ILI . <br /> : ' h ,. <br /> fir <br /> Y7�,. 6 <br /> tt - `r <br /> F is 1'1%1 I -r . G t t r <br /> C7 I . , <br /> y <br /> EI-10 42-D4 <br /> Ru <br /> 10!Yl;ri7: <br /> a, <br /> d SfPTAiE CLEANERS REPpRT <br />