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C a <br /> RECEIVED <br /> C <br /> ' SAN JOAQUIN COUNTY <br /> . . . RECEIVED1 <br /> ' OC 114 2014 <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this=month form <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232: 12t" ref each <br /> •' Telephone.,(209)468-3420 Fax: (209);464=OfH Webs www.sjgov.o 2014 <br /> bMRONMENTALHEALTH '�1 5 <br /> LL. ''_``«a' PERMITISERVICES SEPTAGE CLEANER'S REPORT <br /> W `( vR <br /> Company Name: iI YY1I f t Ike wFer, , year �� <br /> Company Address: �i t4 i cly q£i 1241 02 LI <br /> % `lam�3'Z Signature: E � �'� �I��'t��`sey'_- <br /> SlreetAddress / City ZIpGQde <br /> All information submitted must he corn tete, accurate, and legible <br /> DATE NAME OF.BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G). GRUSETRAP FACIUTIO <br /> t, t >} PLEASE INCLUDE STREET N, DIRECTION; STREET NAME AND CITY C' CHEMICAL <br /> l+`I`1 cry,` {_ Z 54 41- Vf city , <br /> �! Witc, <br /> cin : Atm <br /> co <br /> N 111 toy ( L tet. �,f u _ city ! ' :a <br /> Nt � � <br /> 6 4a LIP— city La-W-1 rup <br /> IILI <br /> x 1 M <br /> I ,!t{ c6 t�tr� vhvt. (L� 4 city <br /> ori, TprL C-1 <br /> GcYC2� 1 f?t. f <br /> 1 I t`1 I fit�G(.2tr tr civ ,,! L <br /> It r>1 14 1 471?1r j--_S 1 q ti r2 . aty <br /> ! " ! o city <br /> /M-o:gci-ae.v':�`a L' C <br /> e el <br /> l city <br /> Iih 7 r Lei ,. C; M.vt inn . o <br /> L �� 7 7 c P Cit 1 <br /> O . .. . . a� <br /> PA <br /> N a <br /> d EHD 4M4 SEPTAGE CLEANERS REPORT <br /> 10!4/07 caof <br /> 0 <br />