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SAN JOAQUIN COUNTY <br /> - L Return this form b the <br /> EWRONMENTAL HEALTH DEPARTMENT y <br /> 600 East Main Street, Stockton,CA 95202 3029 12 of each month m <br /> A Telephone:(209)468-3420 Fax:(209)464-0138 Web:%-,nwuvsjgov.orglehd CD <br /> PTAGE CLEANER'S REPORT w <br /> Company Name: XReport for the th of: yearx:�1.3 w <br /> w Company Address: V signature: ' <br /> Street Address CRY ;5P Code -1 <br /> W z� <br /> o All information submitted must be complete, accurate, and le ibla O <br /> iv DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DOME GALLONS tw REME"AL NAME OF TREATMENT <br /> PUMPED FRDPERTYOWNER PLI11tPFD tC'� ' FACILITY <br /> w PLEASE INCLUDE STREET IF, DIRECTION, STREET NAYS AND CITY CHESUC4i O <br /> H <br /> Cly O <br /> H <br /> ti <br /> CdyD <br /> CAY O <br /> z O <br /> o � <br /> w C <br /> ti <br /> ry <br /> V1 <br /> I U1 <br /> tl <br /> lD <br /> CRY <br /> Ql <br /> U\r m <br /> tD <br /> Cey <br /> y1��lG�s <br /> city <br /> cAiy <br /> O <br /> r <br /> ro <br /> Q <br /> �D <br /> cay <br /> .A <br /> 0� <br /> m <br /> W <br /> 0) <br /> City <br /> cfty <br /> '0 <br /> E-®42-08 SEPTAGE ClFANERS REPORT <br /> 1aero7 <br />