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E k ` <br /> SAN JOAQUIN COUNTY <br /> - ENVIRON1,1ENTAL HEALTH DEPARTMENT - Return this f43rin by the <br /> 600 East Main Street: Stockton,CA 9E202-3029 a ' 12"'of each month <br /> rl - Telephone: j209)488-34201 Fax:(209)464-0138 Web:vA,,"w.sigov.orglebd <br /> SEPTAGE CLEANER'S REPORT '`L{{' =,!E,F -.1 V <br /> Company Name: Wam_, Report for the mowlih of: year Q C <br /> CL <br /> Company Address: L, Signature: :f}n Lao- <br /> .-1 <br /> slr"t".ddrss City y Z-o rodL <br /> ❑ <br /> F� All information submitted must be raw accurate. and legible <br /> RR} <br /> DATE NAE OF BUSINESS OR ADDRESS WHERE WORK WAS DANE GALLONS RMOENnA� NAME OF TREJ4771gENF <br /> PUMPED PROPERTY OWN ER PUMPED �G} GREASE TRAP FACILITY <br /> P- PLEASE INCLuaF STREET P, 61PEC:TIOH, STREET NAME ANP CITY G Ct1EMICAL <br /> city <br /> ON, <br /> Gm ° ---- <br /> Grt <br /> COY - -— <br /> rn <br /> cr <br /> o airy <br /> X <br /> Cr �— _ CFO <br /> _. _city <br /> — <br /> L1J <br /> C <br /> wC1 i <br /> W <br /> U7 <br /> C� Cint <br /> CC — --- --- — <br /> � _ k <br /> 1 :,i ------- i <br /> � CiEy <br /> r3_ <br /> LL <br /> Q cih, <br /> -.1 <br /> CL <br /> Y <br /> .. FHD 42-04 SEP r,SGE CL E.;',EYS REPORT <br /> 1014.07 <br /> rr❑ <br /> LL <br /> i <br />