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■ilii■ <br /> ■ ■ ■ ■FI� <br /> SAN JOAQUIN COUNTY m <br /> Return this form b the w <br /> �' :• ENVIRONMENTAL HEALTH DEPARTMENT Y <br /> 600 East(blain Street, Slockton, CA 95202 3029 12 of each month ru <br /> Telephone:(209)458-3420 Fax:(209)464-0138 Web:urww.sjgov.orglehd � <br /> — �' SEP AGE NER"S REPORT <br /> e ar month of: year <br /> T Company Name; � � <br /> Company Address: - - --- Signature: <br /> St:eet Address GAY LP Code <br /> _ All information submitted must be complete, accurate, and legible 3 <br /> C::> DATE NAME OF 8U51ilESS OR ADDRESS WHERE WORKiYAS DOME I GALLONS tat ' N"E OF TREATMENT D <br /> PUMPED PROPERTY OWNER �G� c� <br /> AP� <br /> ELEASE INCLUDE STREET 1, DIR EC 710 N, STREET NAf1E AND CITY PLIMPED C C}¢6MAL Y9G� FACILITY r- <br /> H <br /> o ` O <br /> — cZy 7C) <br /> � Z <br /> � ` H <br /> � D <br /> O <br /> Gd F- <br /> �n <br /> C <br /> t <br /> city <br /> U VI <br /> (A <br /> IDCity <br /> CD <br /> w <br /> ctv <br /> EbUIFIONME.NTAL HEAL(,l r-0 <br /> (Am <br /> PERMITISERVIUtO <br /> My <br /> CT) <br /> m <br /> cdyw <br /> co <br /> SAI <br /> cay <br /> EFID 42-04 SEPTAGE CLEANERS REPORT <br /> 1014A7 <br />