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m rRcu ,� RECEIVED SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APR 0 9 2018 11868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> W fna <br /> 4 Telephone:(209)468-342D Fax, (209) 464-0139 Web:www.sJ90v,0rg1ehd 12'' of each month <br /> ENVIRONMENTAL HEALTH <br /> PERM T ER ES SEPTAGE CI?EANER;e$ REPORT <br /> Company Name: <br /> or/� hl�s <br /> of Report for the mo hof: c yearao/f� <br /> Company Address: /// � �5. �'�3s' Signature: <br /> SUe�1 Adu`rss city , y` <br /> Zip Cade <br /> All information submitted must be com lete accurate, and ie ib}e <br /> DAH NAME OF BUSINESS OR <br /> PUMPED PROPERTY01n1NER ADDRESS WHERE WORK WAS DONE GALLONS {R):RESID:B-MALPLEASE INCLUDE STREET N, DIREC-TrON, STREET t4Ar,1E 0.rJO Crit (G1L p NAME OFTREATII7PNT <br /> U PIJ}tRPEDz . J C ./, (01l. FAC11]TY <br /> co <br /> OZ <br /> LLJ <br /> �vyo tl,�rj Cay <br /> Ci ,3 s oC, 0, . <br /> ci <br /> / <br /> .J 6 IYfC`7 1 .Y l�[ �Y De <br /> cII rrsc �i� 3 /� <br /> C <br /> 9 ") <br /> uly <br /> � CIS <br /> C`I V e1 "T9 Lei G Cil �� ! m <br /> 71 <br /> N <br /> m ci o <br /> N � <br /> • I <br /> Ci <br /> N <br /> Cn - <br /> Cit <br /> 4 <br /> a� <br /> co <br /> r-I <br /> CD CiL <br /> N <br /> CSD EHD 42-04 <br /> 12127133 <br /> U <br /> M SEPTAGE CLEANERS REPORT <br />