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aZM•F <br /> Na ky ll i an � <br /> SAN JUAQLIN COUNTY <br /> .0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT �� , " Return this Form by <br /> 304 East Weber Avenue,3`�Floor,Stockton,CA 95202-2708 •�=• • �. �th�I2th of each month <br /> Arg <br /> Telephone: 209 468-3420 Fax: 209 464-0138 Web:www.s-lgov.org/chd <br /> ENVIROMENT HEALTH <br /> Q R��� gp P/ SEPTAGE CLEANERS REPORT <br /> y �j <br /> r r 1/ Report for th month f: <br /> CompanName: �MWlf f({ year <br /> Company Address: <br /> aa 4N. . '( ; V Pr- �C��_ �� had dga (l Signature: 1-- <br /> Street Address City Zip Cade }S,3s1 <br /> All infurnnatiun suhmilted must be cum Tete, accurate, and Ic ible <br /> 00ti <br /> 0) DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) Reslnr.xrlAl, <br /> {G) cRF:v+se'tx►e ,SAME Of+'1'REA'13+fENT <br /> I? PUMPED PROPERT'YOWNER yLEASL INCLUDE: SIXF.E:I' k. DIRECTION, STREET NAME AND CITU PUMPED FACILITY <br /> Or` � C CHLMlCAL <br /> CV <br /> City <br /> City <br /> city <br /> City <br /> City <br /> Cily <br /> ei <br /> . _........__. City <br /> Ciiy <br /> City <br /> Ciry <br /> tl Cily <br /> .Q <br /> m City <br /> V7 <br /> CY Cily <br /> Q C,1v <br /> I'i1y <br /> N <br /> 0) Cily <br /> LIQ - <br /> cily. <br /> Q <br /> e- <br /> _ Cil} <br /> O <br /> CL F,HD 41-02.04 <br /> Q R!3IX2W 4 Scp1i'yCesapuu1 Rrpu:i <br />