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SAN JOAQWN COUNTY <br /> ,r- EMVIRONMENTAL HEALTH DEPARTMENT Rtiurn this form by the <br /> -ocr M !2`h of each rnorAh <br /> Street, S1, ton, CA 95202-3029 AR 20 <br /> 600 East Mon <br /> w 468-3.42D Fax:(209)4664-0138 Web:WWW.Sjg0V,Drgfehd <br /> bit <br /> Telephone:(209) <br /> -N— <br /> EPTAGE CLEANER'S REPORT <br /> Report for e 'year <br /> Company Name; <br /> Signature:Company Address: SUee AddadM city Zip Code <br /> plate. accurate and ieg,ble <br /> All information submitted must b cont (R) RESOMT6& NAME OF TREATMENT <br /> DATE NAME OF BUSINIM OR <br /> ADDRESS WHERE WORK WAS DOME MWED (G) GREASE TRM FACILITY <br /> M -Cito", 5 NAME: AND CITY j GAi�Lo" CwMr-AL <br /> P LMP ED PROPERTY OWNER PLEA5e INCLUDE STREET 8, DIRE STREET --7 <br /> -i I -- -- <br /> <1 <br /> city <br /> 7 5�7 <br /> 0 <br /> 0!!k <br /> C4 <br /> citw <br /> CD <br /> LID <br /> Ct <br /> ori <br /> CV <br /> Gib <br /> CV <br /> city <br /> cri <br /> C-4 SEFTAGE CLEANERS REPORT <br /> EHD 4z--04 <br />