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RECEIVED <br /> a4A41i SAN JOAQUIN COUNTY OCT 0 5 2018 <br /> �'erF�SA <br /> �,. ENVIRORfv1EWTAt HEALTH DEPARTMENT Return this form by the <br /> 18£8 East Hazelton Avenue, Stockton,CA 95205-6232 EI�1/IR��IA�ENTA! HEAL 12t' of each month <br /> ,•;F� Telephone:(209)468-3420 Fax:(209)464-0938 Web:vA%w.$)gov.orgleTi'd"'iVSERVICES <br /> jj SEPTAGE CLEANER'S REPORT �� j� <br /> Company Name: ( Q � �4G oc w Report for hem h of:6 year t <br /> Company Address: S Signat <br /> SBeet A ess City Zip Coin <br /> All informatlon Submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RFsioFrmw NAIVE OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREAGETRAP FAC1LtTY <br /> PLEASE INCLUDE STREET 8, DIRECTION, STREET NAME AND CITY C CHMICAL <br /> ('19 1 <br /> S� <br /> �j v �- crcyt.( (i <br /> city <br /> city <br /> city <br /> cpy C-' <br /> I <br /> city ¢ <br /> 0 <br /> city <br /> rn <br /> cityt <br /> 0 <br /> ca cr <br /> city Lci <br /> CRY _ <br /> O <br /> city <br /> E <br /> city <br /> Page of -a <br /> EHD 42-04 SFYTAGE CLEANERS REPORT <br /> t 2/27!t 3 <br /> a> <br /> rEX%% <br />