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Kr:.I�CiVGV <br /> �'`Y'•'Y SAN JOAQUIN COUNTY <br /> OCT 30 2014 ENVIRONMENTAL Return this form by <br /> 600 Cast MainStreet,Stockton,CA 95202-2708 the 12'"of each month <br /> Telephone.,(209)468-3420 Fat::(209)464-0138 Ifeb:www.sjgov.org/elld <br /> .:`r: ENVIRONMENTAL HEALTH <br /> PERMITISERRVICES <br /> Sl CIPTAGE CLEANER'S RE,PORTCL <br /> � <br /> Company Name: '1 _ Report for the month O - yearZCfiN <br /> n <br /> Company Address: --- �i�� S- '�� �UY`�fi(J4 "lam _ ,Signature: _- <br /> Street Address City Zip code <br /> All inrormstlon submitted most be cons Tete, accurate, and legible <br /> DATE NAME,O1-BUSINESS OR (R) RESibENTIAL <br /> � � � ADDRESS\VI[ERC 1VORiC WAS DONE GALLONS (G1 GRF.ASF:TRAP NAME OGTREATMGNT <br /> PUMPED PROVE O\VNL,R PUMI LU FACILITY <br /> PLEASE IpCi,UPF, STREET M, DIRECTION, STREET RAt11E AND CITY (C CIIlINICAI <br /> f� <br /> Cltl ._ -_... ... <br /> rn <br /> 0 City <br /> ily <br /> cit <br /> Y `v P ck C y`1 <br /> Cil <br /> ci <br /> City <br /> cit m <br /> r` <br /> Cit o <br /> z <br /> Cit <br /> 0 <br /> City <br /> m <br /> Cil <br /> _ Cil <br /> — - o <br /> N <br /> --city V%A A.0co o <br /> Ci! <br /> V <br /> Cit <br /> CD cityto <br /> t- <br /> ----— Cil _ > <br /> a� <br /> CNv <br /> M � <br />■ ■ ■ ■ 7 0•t <br />■�::■�_ Septic/Cesspool Rrtx,rt <br />