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tl <br /> DECEIVE® <br /> D °`7r SAN JOAQUIN COUNTY <br /> MAR oil <br /> a ENVIRONMENTAL HEALTH DEPARTMENT 2014 Return this firm by the <br /> r 1868 East Hazelton Avenue, Stockton, CA 95205-6232 2ih of each rrtonth <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:wmv. U�t E��H�.TM <br /> SEPTAGE CLEANER'S REPORT PERMIT/SERVICES <br /> Company Mahe: J +1 + Yl:i '-`,, lC Report for the month of: � year <br /> Company Address: � �✓ %� C�Lf, �'?r'� `f-ji;•"> } ,., , t <br /> 1 �� Signature; —,-,A - / a Z46 <br /> Street Address ! City Zip.Code <br /> All information submitted must be complete, accurate,. and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED {G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE. STREET p; DIRECTION, STREET NAME AND CITY G CHEMICAL <br /> { t✓)�_"�i•L•t_3 � �� � �,z:` �.r `t�'�1 <br /> city I :L ��� f. (f.�,.� f`�• 1 r�Li 1� <br /> rVtSf 1 r ( t Cil <br /> fill '1 1 LCL Jt y 141, <br /> j 1 -HrL t tzJ 7 L'{.: PI� ' I t C .J .s t 1`' �i1- ! ""'L-'` Ci- '�'"L` � ..%4�CJS t 7 r l.G 'i. <br /> (] t1e litnvcity (' t' _ - ( v)- <br /> � l t1 1 (,'j �`" bz�-f r�p 1� (,�t�.f c�� ar ����r�`�C.�..�.- ;'101) <br /> m t 0 14 1-S a1/4a,: { k' I r , . ( �4��s j rx v I1t f <br /> o ; city <br /> rn.Z4, q -E'rri t 9 city <br /> p )-q .� t n' !'f SYS G tis e , Ci <br /> N ✓ tf lis � � m <br /> iG , 0 t-'6J <br /> 14 re. mi a7�-' 'i iti '4� Cif ala a eL �- —) 0i 00 <br /> tv <br /> 1" C LLR ' 1-upv..> Ci 6 � U =�1vv CJ r AY S cam, <br /> l F��rty' <br /> 441w_ <br /> 3 L <br /> .� h i- - n P i <br /> ] 'ldier+. ,. pita ' '1 L Ci iC`G' <br /> l Gt-" �:� <br /> art <br /> Ci <br /> N <br /> 0 Ci?y -o <br /> N a� <br /> tl <br /> tl ip��� SEPTAGE CLEANERS REPORT <br /> a <br /> ii <br />