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RECOWEID1 ST <br /> M <br /> .SAN JOAQUIN COUNTY124 <br /> P <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUL 0 8 2010 I Return this form by the <br /> hu AW: 600 East Main Street, Stockton, CA 95202-3629C�l �p� 12w of each month <br /> Telephone:(209)468-3420 Fax:(269)464-0138 Web:www.sjgoV,t>fV�l NNIENT HEA <br /> .` <br /> SEPTAGE CLEANER S REPORT PERMIT/SERVICES <br /> Company Name: xr c>CK+on ?obd 'Roo+e I- Report for th nth of: J �,'� year � <br /> Company Address: _ L47-2-i3 N tWta� Rd .�a+Ock_ trl q5 20 5 Signature: <br /> Sheet Address Cily Zip Code <br /> All information aUbmltted must be complete, accurate, and le Ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHE RE WORX WAS 0014 GALLONS (R1 ""'DENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTYOWNER PEIMPED (G) GREASE MAP FACILITY <br /> PLEASE INCLUDE STREET E, DIRECTION, STREET Nik11E AHG CITY G CH£NICAL <br /> � i f� 1 its i30D 3+� Y2 i K►� iSoD <br /> O Z P I L/. s 1- e`'o r cI f 4-M OD <br /> Cao U t2 OL) kw Ie rr cI JL J r <br /> rn o 2 Gt. e.6 t 5e �,P� �rq 5 'iZY a glr_ n r o C J t f'V 2, 5.2 Sim <br /> t`3r.��ier S &-�o rle- <br /> co 5'17 Af 33 Z 3 <br /> • o r►ne I Ends 140 q o 4,ve - S',1 338 2. 04 <br /> r tro iw,e �' 5 icanC� 2 S I k Af 338 - <br /> oGL- 1240 30 <br /> L/r � �f�+�� L.`T�� I V 1� �?� ci '•^���- 2 rr c7C.t ti's <br /> J ' 4e r 2-Gf 4-V,� Gr-ar+- ,n CSI � <br /> Jco4 G-EG' r"�Urrbroi Eve c4ty <br /> i.e5r ZEG E McLT'G 7Ln CIVS'T1GIV lS�� <br /> far Y5 e R>sY r + Cfty <br /> I n -P\2:5+u'' �. t c 1G f 2 oo <br /> Y-xf 112 25 u�L c S�i !til Q �" <br /> a 5ot3q Oy le-N 1200 n <br /> -Po' 5 iR?o co STXP1 33S-') <br /> r <br /> o (O rcfG_ �- J'! . 1 o a i r c� ��G�1 �cV82 G <br /> N ri f�#o 4 G �r � � c 'ri�U .33132 C3 �� <br /> pp EHD G2-0� SEPTAGE CLEANERS REPORT <br /> Q 10MID7 <br /> �3 <br />