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SAN JOAQLIN COMM' <br /> 9 EwIRONwNTALHEALTtiDEPARTMENT Return this form by <br /> 304 East Weber Aveuue,3n6 Floor,Stockton,CA 95202-2708 the 12"'of each month <br /> fl Telephone: (209)468-3420 Fax: (209)464-0138 Tileb•www.sigov.org/ehd <br /> SEPTAGE CLEANIER'S REPORT <br /> Company Name: ,: ) t " �'' � Report for the month of: 7 year <br /> Company Address: ` � fl,),,Signature: <br /> St-d Addrrsy City Zap Code ✓ <br /> AL1 information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUS74ESS OR ADDRESS WME WORK WAS DONE GALLONS (R) RFIIDEKr1A!• <br /> NAME OFTR]'•ATtvIET�IT <br /> PUMPED 1'ROPERTI' \1' <br /> ONEit P L E A S E I N C L U D E STREET a, n I R E C T 1 0 r, STREET TAME AND C I TY PUMPED (C) C33EMIC-AL RACQ.ITY <br /> C /'�ic.�j✓� (.'[.' i d!/GIJI I—r.til <br /> J �• i��'/ /.�j��l ( K�rtJ i/1c iZ1 ' c C � f rl 5 Ciry 1 i <br /> I <br /> 1-13 - /7 J -�sz��.��✓r,:/�4we ' « f.✓� <br /> City <br /> 7-17 J'i%l e /1 e',��f � `tai; <br /> cin• <br /> /7 119,11e;1me ;Gla./ L"-el ;S L' Gtr• <br /> i <br /> '1 Bl!'N'� an• <br /> Cih' <br /> City <br /> /�� )a City <br /> CiLv <br /> Otv <br /> 0zi -� cis cm. s <br /> City <br /> i <br /> City <br /> i <br /> CRY <br /> City <br /> city <br /> Cin• <br /> City <br /> Ci y br <br /> E11D 4204 ENVIRONMENTAL HEALTH <br /> 8130/04 PERMIT/SERVICES <br />