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SAN Jdr1( UINI COUNTY 1 l <br /> ENV IRONNIENTAL HEALTH DEPARTMENT Return this form y <br /> ) '�'• IJ 304 East Wcbcr Avenue,3'd Flour,Stockton, CA 93202-2708 ���I�II'�f h InOntls <br /> Telephone:(209)468-3420 Fax,(209)464-0138 Web:%vww.sjgov.or Ichd 37miNVIRCINMENTAL <br /> 1SEPTAGE CLEANERS REPORT HEALTH <br /> Company Name: rI � I MIT/SERVICES <br /> i ► Report for the month of year <br /> l� <br /> Company Address: 1 h n D��' r Sff Signature• ' <br /> Street Address t;t�. T.,p rude <br /> r~ All Informntion sultnliltcd utast be cam Mete, nrcurUlr and lr able <br /> m DATE NAVE OF BUSINESS OR1DDItE551{'}iF,Itf 11rORlC 11'A51)Ut�E GALLONS <br /> (R) RESIUEN" IA1. <br /> co PUMPED PROPERTY OWNER (G) CREASE VRAI' NAME QI TREATMENT <br /> C6 PLEASE INCLUDE STREET M. DIRECTION, STREET NAME AND ' PlAtIPED FACILITY <br /> N CITN (Cl L71ESIlC,U. <br /> d1 <br /> CD <br /> N Pity <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> C <br /> Ciry <br /> s"l City <br /> City <br /> c"ily <br /> Ell <br /> cY — - --- City <br /> 06 <br /> Q <br /> ^— City <br /> (6 <br /> (fit Coy <br /> 71F <br /> -- U.IN. <br /> a� <br /> co Cr1ti <br /> i'Illi•I;•ti:toed <br /> N M1l1IIis4 SepucK"es;p,ulKeNrl <br />