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4'_:.�.:•�:?�• SAN,1QAQLtI\ COUNTY RECO NOV IV nnn <br /> ENVIRONMENTAL Hi-m.m DL•PARTMFNT Return this farm by <br /> ' 304 Enst Wcber Aventie,Std Floor,Stockton CA 95202-2705 to <br /> F�• - e 12 of each month <br /> Telcplrunc;(209)463-3420 Fax;(209)464-0138 Web:w%v%v.sjgov,orglehd <br /> a SEPTAGE CLEANERS REPORT <br /> Company Name: r j �l r i Repurt for the month of: I C41 L year <br /> Company Address: r 1 r .5t 1 a f'►�1Lk��,�c,,CR (?S 3S, Si n,Jtare: <br /> Sing!address Ctta zip Carle <br /> F` AAI infurtDnlion Submitted must be cam lete, uecurute Rnd le ibie <br /> co <br /> DATE NANIF OF BUSINESS OR ADDRESS WHERE WORK WAS DONE (R) RESIDE\TL\L <br /> P[t11PED PROPERTI`014'\Eit GALLONS (G) CREASETRAP PUMPED (C) C3IE.lF[CAL ,\,1h1F.OF TREATMENTc') PLEASE INCLUDE STREET k. DIRECTION'. STREET NAM4 AND CITI' FACILITY <br /> CV <br /> Q) <br /> N Cily <br /> CiTy <br /> Ciry <br /> Cin• <br /> tlry <br /> Cily <br /> cily <br /> ny <br /> City <br /> city <br /> City <br /> .o Ji Ciry <br /> Q <br /> co Ciry <br /> to <br /> U City <br /> la <br /> C� <br /> Ci1v <br /> CL <br /> II] ' <br /> CD <br /> CD <br /> O <br /> Cti} <br /> Z <br /> R-In NmI4 9cpnc.K'essVw1 Pepnrt <br />