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RECEIVED <br /> SAN JOAQUIN COUNTY <br /> MAR 0 9 2011 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> LU 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> cI .`4cf ���` ENVIRONMENTALHEALTP/elohone: (209)468-3420 Fax:(209) 464-0138 Web:VV vM.s19ov.or9lehd �2�' of each month <br /> n PERMIT/SERVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company blame: Z�jla 0,/a Y3 c_! <br /> / Report for the m of: 6 year add <br /> Company Address: _ ?O! 2osca,r /Qo� a <br /> Sireet Address �� ��/�� Signature: <br /> C) <br /> y Zip Code <br /> A11 information submitted must be com ietD, accurate, and legible <br /> DATE NAME OF Bi15114ESS OR <br /> PUN YPED PRO PERlY OWNER ADBRE5S WHERE WORK WAS GALLONS IR) RESIDENTIAL <br /> CJ PLEASE INCLUDE STREET k, DIRECTION STREET t{ALAE AND CITY ) GREASETRAP NAME OF TREATMENT <br /> G <br /> .y F q� Y v PUlAPED {O� CHEMICAL <br /> FACiL1TY <br /> co <br /> LLI <br /> r/ ci r.. q r c <br /> ry <br /> 00 Cqy <br /> �7ov <br /> Cqy <br /> IL <br /> f'r <br /> city <br /> o y� w..,f L4., <br /> -e Gil e?e / ay3 /2 ,70 o <br /> ay u ! ' <br /> City <br /> M 190City <br /> -Pt <br /> N <br /> i <br /> L0 Ci4 F— <br /> CS) <br /> m <br /> N o <br /> Cil cr <br /> 6 <br /> v _ <br /> City � <br /> Cil <br /> CD <br /> N Ct! <br /> CT) Page of <br /> END 42-04 a <br /> M M 121271'f 3 <br /> SEPTAGE CLEANERS REPORT � <br />■'M M%?N% <br />