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.-f ,aPR>ll ICS <br /> SAN JOAQUIN COUNTY RECEIVED - <br /> "` ENVIRONMENTAL HEALTH DEPARTMENT <br /> m 1868 East Hazelton Avenue, Stockton,CA 95205-6232 'PR 1 ;'j 2p 419 <br /> Ret <br /> this form by the <br /> '✓ <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov, 't2 of each month <br /> org/ehd <br /> ENVIRONMENTAL HEALTij <br /> / / SEPTAGE CLEANEW6 REPORT PERNJITISEMACES <br /> Company !Name: 07 r L <br /> ' c Report for the th ofLj <br /> Company Address: : . <br /> year <br /> Sheef Address Cn� C4 9S3S7 Signature: ` 014 A v <br /> Zip Code <br /> AU information submitted must be cam rete accurate, and le ible <br /> DATE NA@AE OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS GONE GALLONS (R) RESIINTIAL <br /> PLEASE INCLUDE STREET ➢tRECTla fl, STREET NAf9E ANO CITY pUMPED kGl GREASE TNAP NAME OF TREATMENT <br /> H CGI Y G FACILITY <br /> Z 'p CJ CHE <br /> MICAL <br /> w �/G tg7ti �/ c �/ ~� 33?7 <br /> J C' <br /> CQyC <br /> 03" r .rr / c �6pQ �Qir crtgS •r <br /> ,L dIL41 <br /> f/ _ Cil ✓q h 2 <br /> a <br /> C17 city <br /> Cil <br /> Ci <br /> rr <br /> .3w d�' 0-0,.9 WTe <br /> D MeChy <br /> ��fr7 <br /> �N Cit <br /> 907 c?ae aif rrw or �.. S cu Lo <br /> G1 <br /> m Cil N <br /> i <br /> Cil a <br /> LO <br /> m Cil <br /> lO <br /> ti <br /> city <br /> Ot <br /> N <br /> m ERD 4204 Page O( <br /> � fY/DHS <br /> m SEPTAGE CLEANERS REPORT <br />