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1-1 RECEIVEt) <br /> SAN-JOAQUIN COUNTY <br /> APR 0 b 2011 ENVIRONMENTAL HEALTH DEPARTMENT <br /> Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> `` 12th of each month <br /> 4c � �; PEMIT/, MM3H Telephone: (209)468-3420 Fax;(209) 464-0138 Web.wMrWMES .sjgov,orglehd <br /> SEPTAGE CLEANEW$ REPORT <br /> Company Name J`�5 =.Y. <br /> Report for the nth :� <br /> Company Address: .?74 2 year <br /> o ca-r Ind �� o �� 'S 3f' Signature: <br /> Street AaarEss y rip Code r <br /> All information submitted muSt be cam fete, accurate, and fe ible <br /> DATE NAME OF BUSIPfESS OR <br /> ;rOPED <br /> PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLOhlS {R� RESIDENTIAL <br /> C1 PLEASE INCLUDE STREET 4, DIRECTION STREE7 KA[iE AND C[7Y (G) GREAsr7RAP NAT�tEOFTREATMEN7 <br /> Z ^ PiJMPED C CHEMICAL FACILITY <br /> ;Z7` Qom/ <br /> w , city of ►` OV <br /> ��Qg�Pc <br /> q <br /> ��� •r / cit r� <br /> ry We Of ,1 't Ile .. <br /> < ca r •t 0 C Pdop4b d L/Low cif v.. <br /> rt r g o. .. cl <br /> Awl cit li^ye e v40 � S.,rAr <br /> r a a <br /> �ysc C�.� /°G t• �i <br /> CV <br /> V <br /> m Cl <br /> CV <br /> U. CII <br /> m <br /> CD <br /> CV o <br /> Ci cr <br /> l <br /> r-t <br /> D Cily <br /> � Q <br /> f� <br /> m <br /> Cv Cil <br /> m Page of <br /> F-ID 42.94 a <br /> M 12!27!13 <br /> M EPTAGE CLEANERS RUORT <br />