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SAN JOAQUIN COUNTY Return this form by � CD <br /> ENVIRONMENTAL HE-kLTit DEP ARTMENT to 1 <br /> 304)East Weber Avenue, <br /> 3`d Floor,Stockton,CA 95202-2708 the 1Z of each month ca <br /> { Telephone:{209)468-3420 Fax:(209)464-0138 Web:www.sjgay.argrehd <br /> ,. SEPTAGE CLEANERS REPORT <br /> / r � A&K <br /> Report for the Eno tb Of: year Q, <br /> Company Marne: L !� 7 Signature: <br /> Company Address: #'xJ z PCOft „ <br /> Sered A ess city <br /> All infarnetior submitted must be ta>a Iete, otccurate and ie i61e {R1 RE$tU[FlCIAL <br /> ADDRESS 4Y11L�RE►FORK 13 AS DONE GALLONS (G) GRens[IVAr Nel►h1E ON TRiA4Th1ENT o <br /> PUr*1P9D FAC[L1TY w <br /> DATE VAh18 OF BUSINESS OR ") <br /> PROPER CI OWN PLEA58 INCLUn[ STREET n, DIR[CTiOA, s'IRP[T HA FSE AHD CITY C CHEMICwL w <br /> PUMPED w <br /> w <br /> City co <br /> m <br /> City <br /> City <br /> City <br /> I <br /> City <br /> Cltx <br /> Ci. <br /> em <br /> Cq <br /> C ry <br /> C' <br /> City <br /> City <br /> Cifv <br /> Citv <br /> cily <br /> rite 69 <br /> O <br /> City O <br /> N <br /> CJ) O <br /> O <br /> N <br /> Sept1s'C'%Sp 1 Repon <br /> EHD 42-121144 <br /> gfi":?rirH <br />