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SAN JOAQUIN COUNTY <br /> a; EWRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 186B East Hazelton Avenue, Stoddon, CA 95205-6232 12c' of each month <br /> Telephone: (209)468-3420 Fax:(209) 464-0138 Web:wvlv.�sjgov_orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Narrle: Report for the nth of: year b j <br /> Company Address: S'��S;�gnature: <br /> SUeatAddrUM-S CRY UZip Code ebb <br /> All intormation submitted must be complete, accurate, and le ible <br /> DATE NAME OF SUSI14ESS OR ADDRESS INHERE WORK WAS DONE GALLONS (R) RESIDETInkL NAIi4E OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GRE[SETF" FACILITY <br /> PLEASE INCLUDE STREET X 131RECTIOt1, STREET NAME AND .CITY (C) CHEMICAL <br /> C-5 (isYACIL <br /> city LC <br /> �)��7� �7 ��� e <br /> city L/ <br /> 3 CiLy v b <br /> l <br /> 0 <br /> o <br /> �e Cit i t c {� <br /> ZC <br /> c !� <br /> cry N <br /> C ity <br /> I Cil <br /> Cit <br /> G <br /> Page of <br /> EH D 42-04 SEPTAGE CLEANERS REPORT a' <br /> 72127173 <br /> ,r <br />