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SAN JOAQTWl Z COMM' <br /> n ENvIRONMENTAi.HEALTH DEPARnENT Return this form by <br /> 304 East Weber Avenue,and Moor,Stockloo,CA 95262-2708 the 12"'of each month <br /> D Telephone: (209)468-3420 Fax:(209)464-0138 Aleb:ww%v.sigov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> l Company Name: Report for the month of. year, <br /> Company Address: 2 (e2i �4 �'; g52toq Signature: <br /> &ITA Addrrsi City Zip Code <br /> All information submitted must be eom lete, &Ccuralr, Sad legible <br /> DATE NAME OF 13USINESS OR ADDRESS NVE[E+RE WORK AS DONE GALLO"1 8 (R) GRERr-RIDE - A1. NAME OFTREATME�IT <br /> PUMPED PROPERW OWNRR PUMPED (C) CuRmI At, FACII.ITY <br /> J) PLEAScC� INCLUDE STREET- 4, DIREC710N, 5'TRr FT TAINC AND CIT)' (C C$iMIC'AL <br /> -TS 0tv 466 <br /> � Cityf f <br /> LU N D city <br /> Cit. <br /> 7 _ <br /> dl,8L Utl Dd City v <br /> > <br /> ad <br /> iL ls� cin d <br /> aR• <br /> s L <br /> D <br /> 1g, t <br /> n <br /> D <br /> v City <br /> city <br /> n <br /> v <br /> n <br /> Cin• <br /> D <br /> Cin• <br /> D <br /> D Cit- <br /> y <br /> V Cit' <br /> V <br /> n EED 42-04 <br /> s/30M <br />