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SAN JOAQUIN COUNTY p <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the a <br /> 600 East Main Street: Stockton, CA 95202-3029 12th of each month <br /> Telephone.(209)468-3420 Fax:(209)464-0138 Web:wYmcsjgov.orglehd <br /> SEPT AGE C ANER'S REPORT A <br /> '2oilCompany Name: Q/7 LLFr Report for the of: �'/ year D <br /> Company Address: �� ✓ � signature:/T( ,� y_/f es o/ o <br /> 5UeSl Zip Ccde r <br /> 0 <br /> Afi information submitted must be complete, accurate, and legible D <br /> G <br /> DATE NAME OF BUSINESS OR <br /> PUMPED ADDRESS WHERE WORK WAS DONE GALLONS tR) RESaDENrutL NAME OF TREATMENT UI <br /> I PROPERTY OWNER CI CflEHaJ M, <br /> D <br /> PLEASE INCLUDE STREET K, DIRECTION. STREET NAME ANCITY PUMPED FACILITY A <br /> G <br /> CI m <br /> e <br /> CHY <br /> D <br /> c---v X <br /> Z <br /> C' O <br /> y� I <br /> VEA <br /> Cify011 LAD <br /> 0 <br /> CI. R�NM1E u <br /> City /SERVlC rH <br /> city <br /> c <br /> crc c <br /> 0 <br /> Coy <br /> N <br /> _ 07 <br /> N <br /> c m <br /> N <br /> C m <br /> W <br /> CRYW <br /> N <br /> city3 <br /> N <br /> ERD 42 04 <br /> 1N4IOi SEPTAGE CLEc.NERB REPORT <br />