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SAN JOAQUIN COUNTY <br /> AUG 7 2009 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> B00 East Main Street, Stockton, CA 96202-3D29 it of each month <br /> w 1 ELVER hone: 209 468-3420 Fax: 9 464-0136 W www.sjgov.org/ehd <br /> �HEA ( ) {20 } Web.www.stgo .orglehd <br /> PERMIT/SGRVICGS SEPTAGE CLEANER'S REPOR .i �` '' ` �4 <br /> Company Name.-! Mc ^�y i' F' ort for tha month of: ,l LJ, year dam` <br /> CornpanyAddress: Lv .lig Signature: �'�g�x <br /> Sireet Addrm C* ZP Cnde <br /> All irtlormatlan submitted must be complete, accurate, acid legible_ <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORKWAS DONE GALLONS (R) NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PLEASe iNCLIPOE STREET 1, DIRECTION, STREET NAME AND CITY PUMPED tGt GREASE TRAP FACILITY <br /> C G CHEMICAL <br /> 4 l 1 , <br /> 3 <br /> O <br /> J <br /> J <br /> a <br /> c <br /> LD <br /> Q <br /> CRY <br /> z <br /> H <br /> Q <br /> LO <br /> C' <br /> Cfl <br /> M <br /> My <br /> Cft <br /> r+ C' <br /> m <br /> C14N <br /> W C. <br /> N <br /> LV <br /> city. <br /> ro <br /> 00 Ci <br /> GIt <br /> ro <br /> LR Cil <br /> 00 <br /> 0 Cel <br /> Cn <br /> M Uy <br /> CD <br /> N Ce <br /> 1-4 <br /> @1 <br /> m EHD 42.0b <br /> SEPTAGE CLEANERS REPORT <br /> iUJAf67 <br />