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CD RECE1�SANJOAQUIN COUNTY (�• <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �U� 1 � Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 2014 12tt' of each month <br /> (D 'rq i'.W� Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sjgot"" d <br /> a �NMENTAL vIHEA <br /> PERMfTicCR ITFF <br /> � SEPTATE CLEANER'S REPORT rES <br /> Company Name: p r v ' <br /> /$ Report for the nth f: U year OV <br /> Company Address: ;?at �o5ee,r �o! ®�,v� a �4. 9��s' Signature: r <br /> Street Address City Zsp CodeAll informatlon submitted must be com lets accurate, and le ible <br /> DATE NAAYE OF B USI NESS OR RESIDENTIAL <br /> PUMPED PROPERTY OUVNER ADDRESS 1UNEItE WORK{filAS DANE GALLONS NAME OF TREATMENT <br /> PLEASE INCLUDE STREET A. DtRECTlON, STREET NAME AND CITY PUMPED (G5 GREASETRAP iFACJLFTY <br /> S CHEMICAL <br /> W 7 ! C' c 4 w / o /C p y <br /> c. <br /> G] <br /> CL <br /> aLc ci v 3Y r rs <br /> Q <br /> Z` fY4 O� f Cil <br /> C 1 Op C LG <br /> Cil <br /> 0 <br /> Csi o0 <br /> CiL � <br /> z <br /> -- <br /> r` rc, <br /> - <br /> m <br /> v — <br /> � <br /> m <br /> CD o <br /> C\1 Crl c� <br /> P <br /> S Ci <br /> � T <br /> v <br /> CV <br /> city an <br /> � Q <br /> v -- <br /> m Ci <br /> 04 a <br /> Page of <br /> ` r=HD 42-04 - a, <br /> OD 12/27113 v <br /> Q SEPTAGE CLEANERS REPORT a' <br />