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RECEIVED <br /> SAN JOAQUIN COUNTY 110V 0 3 201 <br /> a' ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> t Telephone$(209) 4680420 Fax. (209)464-0138 Web: Avw sgov.or6/ehd68 East Hazelton Avenufa, Stockton, CA 95205-6232E�vi�ERVIC ��� of each month <br /> f g <br /> SEPTAGGE�CLEANER'S REPORT �} <br /> Company Name: �y �-�` C� �I CJ- Report for the o t 'Of: years <br /> Company Address: Signatur <br /> 5t>�tALdress City �Cade <br /> All information submitted frust be complete, accurate, and legible <br /> DATE NAME OF SU SI NESS OR ADDRESS VME1RE WORKWAS DONE GALLONS (R} RESIDEMTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER FU64PEO I (G} GRFJSSETRI4PFAGILTTY <br /> PLEASE INCLUDE STREt:T RCHE311CA, DIRECTION, STREET HAFAC AMD CITY c� (C� L / <br /> AL <br /> cityjucK <br /> c • Lc 1 <br /> cl C <br /> A U K <br /> IM C-711 C. <br /> City <br /> cif Ll <br /> i Caa� <br /> 4'1 cit"I L1 r� <br /> 0 <br /> cz C-4 <br /> City <br /> 0 <br /> z <br /> ity <br /> Page of <br /> EH D 42-09 SEPTAGE GLEANERS REPORT <br /> 3?}27fi3 <br />