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SAN JOAQUIN COUNTY <br /> ENVIRGNMENTAL HEALTH DEPARTMENT Return this form by thy; <br /> 600 East Main Street,Stockton, CA 95202-3029 42th of each month <br /> Telephone; (209)468-3420 Fax., (209)464-0138 Web:www.sjgov.org/ehd <br /> Q <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: v -S(' i '� Report for the month or. 0 year 6— <br /> Company <br /> Company Address; 63J`, 4 c- ) " • Signature: Z. <br /> SireEt Address Cdy Zip Code <br /> All Information submitted must be complete, accurate, and legible <br /> PATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) PESIDENTIAL NAME OF TREATMENT <br /> PUMPFO PROPERTY OWNER PUM.PEO (G) ORME TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAtIE ANO CITY C CHEMICAL <br /> }1�I fijrs,! Af?�rti),� rpt F.--,,rn c,r` ; city. e-1 ���� �'C50 <br /> _ r <br /> <~ <br /> Cit <br /> p Cit <br /> m <br /> L <br /> � Cil <br /> pip Cil <br /> C <br /> Ci <br /> rz <br /> Ci AU <br /> CL 1j <br /> rr7 <br /> +' Cir P RMI F�aL <br /> E City 'C�`S <br /> C <br /> o <br /> L Cit <br /> ? Cit <br /> C <br /> LU <br /> City <br /> City <br /> Q. <br /> II) Cit' <br /> Ltd <br /> Q <br /> Q <br /> Cil <br /> .a <br /> CU <br /> 3 c'F{a 42-04 SEPTAGE CLEANERS R=PQ RT <br />