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ttK SAN JOAQUIN COUNTY <br /> ENVfRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> ` 600 East Main Street,Stockton. CA 95202-3029 12t"of each month <br /> • 's -t':' Telephone:(209)468-3420 Fax:(209)564-0538 Web:wwvr.sjgov,orglehd <br /> SEPGF� CLEAN 'S REPORT <br /> Company Name: /� i n G� �j Report forlie th at year /0 <br /> Company Address: 7 .3 3/a 3d Signature: <br /> 0 Street AdDrets Gq Lp Crile <br /> N <br /> All intormalion submitted must be complete, accurate and legible <br /> m <br /> W DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (Rl NesiDwrtu NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) r>FEArE TR^'' FACILITY <br /> aLEASE INCLUDE STREET I. DIRECTION, 5TREET NAME AHO CITY C pl u <br /> N <br /> 0 Cit <br /> F- <br /> I Cit <br /> M <br /> D <br /> N C <br /> V <br /> w C' <br /> tD <br /> Q c ENVIRONM NTAL HEALTH <br /> V) <br /> n <br /> m <br /> r <br /> r <br /> PERM! 3EMVICES <br /> Cky <br /> 0 <br /> CRYo <br /> O z <br /> C07 C :5E <br /> CE <br /> 04 <br /> L <br /> HN <br /> C4CE <br /> czy <br /> O <br /> CE N <br /> 0 �. <br /> CAY <br /> C 7 <br /> In <br /> y C3 E <br /> � H <br /> N at) <br /> 0 <br /> N <br /> i <br /> Q EHD 42-04 SEPTAGE CLE4NERS REPORT <br /> uvaXm <br /> i d <br /> Z ■■ � <br />