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0�"' <br /> RECEIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SEP 10 2014 Return this form by the <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-62327'efe hone: 12th of each month <br /> <1 p (209) 468-3420 Fax: {2D9}464-9138 Web: <br /> °- "`"` <br /> ` " SEWIRONMENTALHEALTH <br /> PERMIT/SERVICES <br /> Company Narne: S SEP��Cs� C�E�.�IE�'� IREP®Rl' <br /> J7r .r Report for the nth f: <br /> Company Address: - �D� �o�en•r IQ� {- ¢� year D/ <br /> Street Address city Signature: �f <br /> Zip Cafe <br /> All infDrmation submitted must be r.om lete, accurate, and le Tble <br /> DATE NAME OF BUSINESS OR �yy <br /> PUNIPED PROPERTY OWNER ADDRESS WHERE IIUORK WAS DONE GALLONS P R�IDEtSRAL NAME OF TREATMENT <br /> }� PLEASE INCLUDE STREET k, DIRECTION, STREET tJAh1E AND CITY PUMPED t l GREASETRAP FACILITY <br /> C1 /� �+ /ff �/ (G} CHEMICAL Z (� "t Oi � 1 � J. 1�� �1 <br /> H � �7�Y� v ca o�l a /C-- <br /> MJ ��/ 1 L � e��j 1�e1/ cit 7 aaO ��`/-` v <br /> <I 35''ss 2 <br /> ci �L <br /> C[C Y JS7/C �P �/ Al <br /> O <br /> CIO <br /> �'4 G♦ . <br /> Git <br /> Ci <br /> m <br /> Ctl <br /> 0 <br /> r� <br /> Cit o <br /> z <br /> r— Q <br /> CV <br /> CD r� <br /> V <br /> cv Ci <br /> Ifl <br /> m <br /> m <br /> Cy Cit o <br /> CA o <br /> <1 <br /> N <br /> �- <br /> tD cn <br /> m I <br /> Ci <br /> V <br /> m <br /> C1l <br /> CS) Page o) <br /> EHD 42-04 — <br /> 17127113 u <br /> m SEPTAGE CLEANERS REPORT a <br />