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r4�1 4 RECEIVED <br /> SAN JOAQUIN COUNTY <br /> CWIIRO14MENTAL HEALTH DEPARTME14T <br /> Return this form by the <br /> JAN 15 20% 1868 l=ast Ilazelton Avenue, Stockton, CA 85205-6232 <br /> "*r kat+ L.• Telephone:(209)468-3420 Fax:(209)46138 Web:Wwvi.9jgov.orglehd �2d' of each month <br /> 4-0 <br /> SNMONMENTA HEALTH <br /> SEPTAGE LEANER'S REPORT <br /> Company Marne: <br /> Company Address: 4L - <br /> Report for the o Of: ar <br /> 3 � / <br /> S3reel 'dress 32�Signature: <br /> Cdy Zip ade <br /> A:II information submitted must be com fete, accurate and le ible <br /> DATE NAME OF ITY OVVSS . ADDRESS WHERE VVORit1RAS DONE TGPt. <br /> LLONS (R) llESJM 4L <br /> PUMPED PROPERTY OWNERNAME OF TREATMENT <br /> PLEkSE INCLUDE S7RE£7 R, D ,ECTIGN, STREET R'AIAE AND CITYBIPED {G} GIFASETRAV FACILITY <br /> (C) CHrMICAL <br /> c. , �. <br /> �r tw I l0 s° r <br /> u <br /> 1 <br /> 33 city (A A 60 R EL <br /> ` 4 CGill c, d LA <br /> CI <br /> (� Cr t b <c <br /> M <br /> °w l/71, 69— <br /> r <br /> Cir K •[ o0 <br /> 10 u o <br /> cr <br /> Lr; <br /> N <br /> C <br /> F- <br /> C <br /> Page of <br /> EHD 42-04 a <br /> 92127/-13 <br /> SEPTAGE CLEA14ERS REPORT <br />