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SAN JOAQUIN COUNTY <br /> m _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> ;F�-A=� Telephone: (20D)46B-3420 Fax: (2D9)464-013B Web:www.Sjgov.orglehd 12th of each nnonth <br /> SERTAGE CLEANEFi'S REPORT <br /> Company Narne: <br /> / Report for the mon of: yearo?F2 <br /> Company Address: �Ol �oseoY �olo ,o o C� 9'�3s' Signature: <br /> Stre�E Address Ci- { —j • <br /> y Zip Ca3z <br /> 'An information submitted must be com late, accurate, and le ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRE55 WNERE WORK WAS DONE GALLONS lR} 1111"AL <br /> PLEASE INCLUDE STREET V, DIRECTrON, STREET NAME AND CITY PUMPED (G) cRCASETRAP NAn9EOF7REATMENT <br /> U ! {C} CHEMICAL FACILITY <br /> car v� i7 <br /> cit �t <br /> dpjLLI0 <br /> (a-d _ Cit <br /> �► 3sy- fj y <br /> �z Cit y 600 � ,► <br /> 3 c Ii <br /> •3' v,2 <br /> 4 , c. •'rs c� (�D <br /> �� Cgr� Y ! � t'isbt�a Cav I GLaw �� �1 <br /> City <br /> Cil <br /> cit 11 <br /> r--- Q <br /> N �-,c•.. d, o C-� <br /> cw � c II R rr <br /> o�b Cit <br /> f, ys / <br /> m b �Y4 v 5 ci <br /> CD <br /> DEC <br /> to � <br /> Et= <br /> CSD <br /> Cit <br /> NOV 13 2017 <br /> cr) Page of <br /> EHO 42-44 <br /> 12t271ss ENVIRONMENTAL HEALTH <br /> SEPTAGE CLEANERS REPORT a <br /> PERMIT/SERVICES _ <br />