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RECEIVED <br /> ul <br /> SAN JOAQUIN COUNTY APR 0 2 2019 <br /> >< ENVIRONMENTAL HEALTH DEPARTMENT [P;I�L7irnthisform byfile866 East Hazelton Avenue, Stockton,CA 9E205-623 ormmonbTelephone:(209)4BB-3420 Fax:(209)4640938 INeh:vmwsj r� �� Nl ENTAL 11 <br /> DEPARTNIENT <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �(i� r S ��� 01L Report fort nth of: (� year a ✓ <br /> Company Address: zS� Signature <br /> Street s Cdy Z-ip CDde <br /> All inform-submitted must be COM fete accurate and legible <br /> DATE NAME OF BIJSII4ESS OR ADDRESS WHERE WORK WAS DONE GALLONS IRI REswE1mAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED IG) ORFeK rxL FACILITY <br /> PLEACE INCLUDE STREET F, DIRECTION, STREET NAME ANO CITY (Cl 0REASET <br /> r - ��Y) SCit, [AGO t JVLLCity <br /> l t <br /> CRY <br /> Chy <br /> Gtty <br /> c' <br /> Le <br /> Cii <br /> City0 <br /> z <br /> L <br /> city <br /> c. <br /> CRY <br /> 0 <br /> C I <br /> city <br /> cry d <br /> c' <br /> c _ <br /> Page_of = <br /> EHD 42 - <br /> 120271M SEPTAGE CLEANERS REPORT <br /> ■ ■ ■ ■ ■ <br />