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1-4 <br /> � RECEIVE® <br /> a ti SAN JOAQUIN CQUNTY <br /> m q ENVIRONMENTAL HEALTH DEPARTMENT MAR 112014 Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ��i11��hh��AL 12t4 of each month <br /> Fa;• ���;� f Telephone: (209)468-3420 Fax:{209)464-0138 Web:K �MEIVTHEALTal H <br /> SEPTAGE CLEANER'$ REPORT PERMIT/SERVICES <br /> Company Blame: <br /> /s c Report for them h of% h year 0/y <br /> Company Address:_ ;?O/ jeo sc.0-e �d �o� ,o,, o �� 1 S <br /> slreef nadfes5 Co2 Signature: e�G <br /> Y Zip Cade <br /> All Information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DOME GALLONS (R) RESIDENTML <br /> PUMPED PROPERTY OWN ER (G) GREASETRAP NAM E OF TREATMENT <br /> PLEASE INCLUDE STREET X, DIRECTIDN, STREET NAME AND c1TY PUMPED FACILITY <br /> Z � •"'���+YO � �Y I (Cl CHEMICAL <br /> H r ' Woo./e� ` 'y/f <br /> t+'� cif we/[. v 7 �'�U fry. <br /> co bG o <br /> W1p <br /> t <br /> MJ ✓■-s •. �-c S cit pop Ir <br /> a A. <br /> 0 o i',c. o, l.� citi hod o . <br /> 07S !� <br /> a �"9Ct ✓rir a.�.� S_ cif i� 4 c ` <br /> ,01 <br /> Q <br /> Cit <br /> Ci <br /> Cil <br /> 0 <br /> rn <br /> Ci m <br /> Cil o <br /> z <br /> CiL � <br /> (` o <br /> CN o <br /> - <br /> m rn <br /> V <br /> CN Ci l <br /> U-) <br /> Cn _ <br /> m Gf N <br /> C <br /> Q <br /> 1-1W <br /> Cil <br /> 6 <br /> CD <br /> Cityn� <br /> (N a <br /> Page_ of---L <br /> EHD 42-04 — <br /> 1) 12127193 a, <br /> CD <br /> iEPTAGECLEANERSREPORT a� <br />