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C � H'Ir,. DECEIVED <br /> m �a`Sa` SAN.10AQ111N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ^ j Re#urn this form by the <br /> m A APR 2016 1868 East Hazelton Avenue, Stockton, CA 9521)5-6232 <br /> Telephone: (209)468-3420 Fax:(209) 464-0138 Web:www.sjgov,orgll=hd 12. of each month <br /> n ENVIRONMENTAL HEALTH <br /> PERMI Eg SEPTAGE GLEANEFM REPORT <br /> Company Name: � p,. c,, 9`v3 <br /> /� / Report for the n nth of; c <br /> Company Address: ��/ /C pxaY rQd ` year` /� <br /> Street Address <br /> 9' 357 Signature: c!c <br /> ci Zip Code • `� <br /> All information submitted must be corn lete, accurate, and legible <br /> DATE NAME OF BUSIWESS OR <br /> PUYAPED PROPERTY 1OWN 14ESSR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDE�JrJAL <br /> PLEASE IPJCLUDE STREET V, DIRECTION, STREET NAME ANo CiIY {G) GREASE TRAP ;NAI.T:EOFTREATMEN'TPUldPED (C) cHe►ncAL ACILITYZ ��~ v rp pjJ �w3/� �• q�T�� It <br /> I35''9s <br /> Ci <br /> b ' <br /> City <br /> 0 3-�� r, r� I ✓ r <br /> 3 ! ,a / Cit 3 y9s °. <br /> -� c-6.. / <br /> Q � �/ _ r��-O`er' Cit ►'qc� 3 �qC� <br /> If-4 X5 Ci ! C- ®r Uc!C m <br /> cn GO C L o <br /> 0 <br /> Cil <br /> 0 <br /> z <br /> Ci <br /> CV CR L� <br /> m M <br /> CU �JI <br /> In <br /> cn <br /> CD <br /> C4 cr <br /> Ci <br /> LD <br /> to CTy <br /> LD <br /> In Q <br /> CD <br /> Cv a <br /> �-i Page °f <br /> END 421 <br /> 12127113 <br /> M , <br /> SEPTAGE CLEANERS REPORT <br />