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iii■i■ <br /> ■ ■ ■ ■ ■ <br /> RECEIVED <br /> �atg ,tco SAN JOAQUIN COUNTY <br /> Q , ` ENVIRONMENTAL HEALT11 DEPARTMENT JUN 0 4 20 Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12'h 6f each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:w"nvMMVf1=NTAL HEALTH <br /> SEPTAGE CLEANER'S REPORT PERM IT/SERVIr,FP <br /> Company Name: Report fort th of L year <br /> 6>4 ---�� <br /> Company Address: 5ignafztre: <br /> Street Address C ly ZFa Coda <br /> 4- <br /> All information submitted must be complete, accurate, and legible <br /> oc {R) A]37n£`lTIAL <br /> DATE NAIdIE OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATAlE�IT <br /> PrUNIPFD PROPERTY OWNER I PUMPED {Gr 3REASETRAP FACILITY <br /> 3�: PLEASE 1NCLUDE S REE'T 8, DIR TION, ETRE 61£ ANI C17Y L) CHPACAL <br /> oov <br /> 4 <br /> CK <br /> City <br /> kt <br /> J it t� <br /> Ci S <br /> city V'a <br /> cst <br /> GAY <br /> ca <br /> CiLy <br /> city <br /> cily <br /> Ci <br /> cily <br /> city <br /> city <br /> city <br /> Page Of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27113 <br />