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■i■i■i■ <br /> >° t SAN JOAQULN COUNTY E12hof <br /> urn this form by the <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> — a + 600 East Main Street, Stockton,CA 95202-3029 each month N <br /> U _ ,i <br /> Q - Telephone:(209)468-3420 Fax_(209)464-0136 Web: <br /> 5� unwvsjgov_orgJehd m <br /> tb' . w <br /> _ //SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> [d Report for the m hof:_ year <br /> w Company Address: 77 .� Signature: X �/� wStreet A4drnss Cit, Zy C3de 71 <br /> All information submitted must be complete, accurate, and legible <br /> 3 <br /> o DATE NAN E OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) NAME NATiIE OF TREATMENT <br /> PUNIPED PROPERTY OWNER PUMPED (G) C"TRAP FACILITY 1) <br /> w PLEASE INCLUDE STREET t, DIRECTION, STREET NAME AND C)TY C CFMLDCAL <br /> ti rf 70.1-r mt 11-' o <br /> Cty <br /> oF <br /> Cdy <br /> SS S— 30 0>iwo <br /> wUY <br /> 47- C4 <br /> 0 <br /> W <br /> Cq <br /> Cdy <br /> CIO <br /> Cky <br /> Co <br /> City <br /> City <br /> m <br /> w <br /> n <br /> '� Frstir . <br /> 0 <br /> ru <br /> CD <br /> m <br /> m <br /> F- <br /> City w <br /> OD <br /> CdY <br /> cay <br /> EHID 42-44 SEPTAGE CLEANERS REPORT <br /> 1(1"7 <br />