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CD <br /> RECEIVED <br /> MAY ' 12017 SAN JOAQUIN COUNTY <br /> CD r $ ENVIRONMENTAL HEALTH DEPARTMENT <br /> { Hazelton Avenue, Stockton CA 95205 8232 Return this dorm by the <br /> w 17c1, of each month <br /> � 1868 East i i <br /> �,,�, �.�,��.� ENVIRONMENTAL HEALTFTe�@phone: (209) 468-3420 Fax: (209)464-0'f 38 Web:vrorw.sjgov.orglehd <br /> n PERMIT/SERVICES <br /> SEPTAOE CLEANER-8 REPORT <br /> Company Name: pr a ,r c'" <br /> S Report for the mo of: r. O <br /> / year�,Z <br /> Company Address: r?Ol cess e Rd ty ,oma v �S gj5W,' Signature: <br /> Street Address City Zip Code <br /> All information submitted must be corm lefe, accurate and legible <br /> DATE YJABJIE OF BUSINESS OR ADDRESS WHERE WORK WAS DONE ;GALLONS (R) RESIDEUML <br /> CJ <br /> PUMPED PROPERTY OWNERNAME OF TREATN➢EHT <br /> Z PLEASE INCLUDE STREET t1, DIRECT10t1, STREET tJAWE AtJD CITY UMPED {C) CHEMICAL PFACILITY <br /> rf { ) cHE1.�ICALo . /!? tLd <br /> meq, Yc le <br /> city <br /> ry S+ <br /> '9 9�► /v �J'90 Cciirw d Cv4*• city �►�4VC• <br /> P4t[ <br /> CHY <br /> 3 9je // <br /> �I ,c 7 NIC `q•�l W Cit /rI7[ '74" d <br /> -� o <br /> . _ o 7" LC-fly C. <br /> gJ►tr���r C.+�w ,►c �4�+t. Cic <br /> Oc r • S C rf <br /> C1404 _ <br /> eft �� Ci p00 <br /> O <br /> L0 <br /> m <br /> CV o <br /> Cit I <br /> LD Cil <br /> Cri <br /> a <br /> r-t - <br /> m � <br /> 04 <br /> Page of <br /> mEHo 42-04 <br /> 1Z1271i3 SEPTAGE CLEANERS REPORT <br />