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L LU Q <br /> SAN JOAQUIN COUNTY <br /> IL ?' �' ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> T.. <br /> o 5; - < 600 East Main Street, Stockton, CA 95202-3029 12"'of each month <br />> N <br /> d Z M r• Telephone:(209)468-3420 Fax-(209)464-0138 Web:%vww-sjgcv.org/ehd <br /> T o wF SEP AGE CLEANER'S REPORT ns, <br /> Jm a Z z <br /> N =Company Name: Q '! 0�i'j�a ' c� I, , • Report for the of: year <br /> m <br /> W Company AddressNe /iP Signature: oc <br /> Strec Aadrrs �Ity Z P Cos <br /> m <br /> N All information submitted must be complete, accurate, and legible <br /> 0 DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RE SET TRAA P NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) OREAEE FACILITY <br /> PLEASE INCLUDE STREET 2i. , DIRECTION, STREET NAME AND CITY a WAL <br /> N <br /> CAY <br /> CI <br /> lli <br /> —cityur <br /> M <br /> G <br /> G <br /> G) <br /> V Gity <br /> r <br /> m <br /> •• <br /> city <br /> z City <br /> ¢ city <br /> L <br /> city <br /> N City <br /> W <br /> Ucly <br /> W O. <br /> N <br /> LO <br /> ¢ <br /> J C <br /> O <br /> C7 <br /> ON <br /> z c <br /> city <br /> J <br /> ¢ <br /> Y <br /> EH042-04 SEPTAC€CL.Fi1Nc2S REPORT <br /> E mtam <br /> m <br /> x <br /> tl <br />