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RECEIVED <br /> ,otat, SAN JOAQUIN COUNTY <br /> d <br /> DEC 10 20% ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-0232 le of each month <br /> f V 1110M 1ENTAL HEA",,home:(208)468-3420 Fax:(209)454-0138 Web:vavw.sjgov.orglehd <br /> DEPARTMENT <br /> SEPTAGE CLEANER'S REPORT l <br /> Company Name: (�r S `��� Ut� Report for th m th of: <br /> Company Address: Signature;---- <br /> Street Addlass City Zip Code <br /> All information submitted must be complete, accurate and legible <br /> DATE NAME OF BU91NESS OR ADDRESS WHERE WORK WAS DONE GALLONS {R) lu3tnl�tnt NAME OF TREAlInENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GRFJ;SE T11" FACILITY <br /> PLEASE INCLUDr. STREET 9. DIRECTIOR. STREET ME AND CITY (C) cHEWCkL <br /> �aCyy <br /> ' cityv <br /> L� u <br /> L car It cp S'6 Lt <br /> /^V T c v c <br /> gab c� City LeGftV <br /> � 4 <br /> 0 <br /> cay <br /> 1 <br /> 0 <br /> co o <br /> I <br /> CRY <br /> Page of <br /> EHD 42-04 SEPTACE CLEANERS REPORT n <br /> 1?1271]3 _ <br /> N E E 0�� <br />