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,• '- SAN JOAQUIN COUNTY r <br /> ' - EWIARONMENTAL HEALTH DEPARTMENT Return this form by the <br /> ru ` 600 East Main Street,Stockton, CA 95202-3029 12d'of each month <br /> Telephone:(209)46&3420 Fax:(209)464-0138 Web:wwdl.sjgcv.crglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ^� le Q11 [G d Report for the mo hof: year a� <br /> Company Address: cC�777 Tim �� yam/ ons. Signature: <br /> Do SI,t Addun: cq zP cucsm <br /> ti <br /> All info rmarion submitted must be com lete, accurate, and legible <br /> 0 <br /> IT DATE NAME OF BUSINESS OR ADDRESS WHERE WORX WAS GONE GALLONS fW R6E)ErrrinL NAME OF TREATMENT <br /> E) PUMPED PROPERTYOWNER PUMPED (G) �ET ae FACILITY <br /> N PLEASE INCLUDE STREET q e1REDT10N, STREET RAPE AND CITY JCI CN WAL <br /> O ci <br /> C <br /> G <br /> C <br /> m� <br /> Mc <br /> N <br /> MGAY <br /> M <br /> CRY <br /> : 0 201 <br /> 0 <br /> ctryJ <br /> CityENV ON RVIC <br /> CE VERN <br /> z c <br /> ch <br /> 0 <br /> LL <br /> CE city <br /> j <br /> E Ciiy <br /> 0 <br /> city <br /> cryro <br /> v <br /> m <br /> CU <br /> .ti C <br /> m <br /> N <br /> I9 EH04M <br /> tIV4D7 5FPTAGE Ct Et AERSREPCRT <br /> CECE <br /> E <br />