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�uI - <br /> Q�� SAN JOAQUJN COUNTY <br /> ENIARONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, StOCMDn, CA 95205-8232 12�' of each month <br /> Telephone: 209)468-3420 Fax: (209)464-0138 Web:www.sjgov,org/ehd <br /> r PTAGE EANER'S REPORT <br /> Company Name: <br /> Report for t dnth of: year <br /> Company Address: - <br /> -reetAAoo s Signature: <br /> I PG <br /> AI( - <br /> Information submitted must be Corn Tete, accurate, and le Ible <br /> DATE N PR PE Bt1 OWNER <br /> OR ADDRESS WHERE WORK WAS DONE GALLONS <br /> PUfdPED PROPERTYOUI'fdER (R} REsiDmTt>;L NAME OFTREATIdENT <br /> PLEASE IhCLU E STREET Q DIRECTION, 57REE7 NAME AND CITY PUMPED (G) GPEAIETRAP FACILITY <br /> C) CHENMAL <br /> 1(( Cit. t�(� <br /> r r <br /> Cil <br /> IQ' GA' 7 <br /> C-r•: t) K u <br /> CIL Gt (� <br /> ci. k cn <br /> IC <br /> 0 <br /> C <br /> 0 <br /> c-'4Cil 1 c <br /> 0 <br /> C' C--4 <br /> bll <br /> a IQ <br /> city <br /> Page o! <br /> EHD 42-04 <br /> 12127113 <br /> SEPTAGE CLEAVERS REPOP.T <br />