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i <br /> RECEIVE <br /> `._.. � ,SAN JOAOLfIN COUNTY ` <br /> l =: ENVIRONMENTAL HEALTH ©EPARTMEN7 1 )I =of <br /> orm by the <br /> 600 Fast Main Street, Stockton. CA 95202-3029 month <br /> d Telephone:(2C 9) 469-3420 Fax:(209)464-0138 Web:VA"���lTl�.H „'� <br /> -' 6wY1 <br /> - SEPTAGE LEANER'S REPORT 4�MfrVl <br /> nl (� <br /> Company blame: � 1"O� ► +�� �� �� . Report for th month Of: <br /> Company A[idresS. <:A��1 CO— Signature: J <br /> Stet Addresn ety Z'P c� <br /> (All Alf information. submitted must be cornfete, accurate, and le ihle <br /> Lr) OATi NAME OF SUSIXESS OR ADDRESS WHERE WORK WAS CONE GALLONS fRF RESIt�T� NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUiMIPED (G mase TRAP FACILITY <br /> PLf ASE INCLUDE STREET X, 41REC T30 N, STR£ET NAME aN9 tI7Y C �{{E1pL <br /> 0. <br /> w <br /> `O „IC <br /> Cih I <br /> r <br /> Cir - <br /> C <br /> � I <br /> 77 — CHY <br /> s <br /> F.1] <br /> .. .CrfY <br /> – -- ' <br /> © Ciy <br /> CE Cm' <br /> G ity " <br /> City _ <br /> U1 <br /> W <br /> city <br /> Uj F I Cilv <br /> UI <br /> L3 ._ _.. .,.... C. <br /> � I <br /> O <br /> 3 City <br /> Z Cite <br /> Q Cy h <br /> LL <br /> J <br /> 42-D4 SEPTAGE CLEANERS?EPDRT <br /> 0 <br /> i <br />