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,a RECEIVED <br /> z` R SAN JOAQUIN COUNTY <br /> m -< © T O 2097 ENVIRONMENTAL HEALTH DEPARTMENT <br /> n I 1868 East Hazelton Avenue, Stockton, CA 9521)5-8232 Return this form by the <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov,orglehd 12�h of each month <br /> Q ENVIRONMENTAL HEALTH <br /> w PERMIT/SERVICES <br /> SEPTAGE CLEANElT$ REPORT <br /> Company !!lame: c <br /> /� s Report for A!h of: yeara�Company Address: �Ol XO � ,�ry� "' oi `�S3S' <br /> naaes5 city Signature: .._ <br /> Zip Code <br /> All infurmatron submitted must be corn lete, accurate, and le fibre <br /> DATE NAME OF BUSINESS oR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORT(WAS DONE GALLONS (R} RESIDEt AL <br /> PLEASE INCLUDE STREET Al, DIRECTIDrd, S7REET NAME AND CITY (G) GREAS€TRAP hIA@dEFACIL OF TREATMENT <br /> V 2 ,/j PLfMPED FACILITY <br /> H �/' � ,/J / (C) CHEMICAL <br /> "' �� � City !fir• 4 - v c <br /> w <br /> �d.Z ✓/figs �j� City <br /> o <br /> n <br /> cityCIO <br /> got CQ, CAo;41�710 C <br /> f T .VV �47 Cir ' �00 #O, <br /> vc �a� �ylr . �'i�5✓' cil � �.� �i <br /> e►• cn <br /> IF <br /> �— <br /> Cir - <br /> 0 <br /> z <br /> Gi <br /> N � <br /> m -- <br /> L0 C' <br /> m r— <br /> m r– <br /> CV Ci o <br /> F <br /> Cr7 0 <br /> co <br /> co C ny <br /> `O o <br /> Ci <br /> CD <br /> CV _ <br /> m Page of <br /> —i EHD 42-04 <br /> 12P27113 <br /> m _ <br /> SEPTAGE CLEANERS REPORT a <br /> C- <br />