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SAN JOAQUIN COUNTY O <br /> _ ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the a <br /> 600 East Main Street, Stockton,CA 95202-3029 12S'of each month x <br /> Telephone:(209)468-3420 Fax.(209)464-0138 Web:Www.Syg0V.0rg1ehd _ a <br /> EPTAGE CLE ER'S REPORT 00 <br /> _ z <br /> Company Name: d Report for the/p/;onth of: year�QI t a <br /> Company Address: A 77 ", Signature: 47� C�s6�(L�l <br /> Street Address Gly Zip Cvda I7 <br /> All Information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS - (R) REs,oEN NAME OF TREATMENT In <br /> PUMPED PROPERTY OWNER PUMPED i (0) DAEASETRAP FACILITY ;aPLLEASE INCLUDE STREET d, DIRECTION, STREET NAME AND CITY C MI <br /> CHECAL <Z <br /> m <br /> 7 3clwaria In <br /> C4 '�5 /6b.s �ncr <br /> D <br /> C X <br /> Z <br /> C 0 <br /> i <br /> city <br /> 01 <br /> A <br /> C ID <br /> CD <br /> city W <br /> C <br /> C' <br /> city <br /> C' <br /> cdyp <br /> Gly <br /> ccN <br /> C N <br /> CJIV0 <br /> N <br /> 0-0 m <br /> W <br /> r <br /> 3 <br /> ro <br /> N <br /> EHE 42-Ce SEPTAGE CLaVERS REPORT <br /> i-VV07 <br />