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SAIti1 dOAQ[IIN COUNTYRECEIVE <br /> �. .P•• ENVIRONMENTAL HEAL'm❑Ei ARTMENT Return this form by <br /> , k, y .' 304 Enst Weber Avenue,3"Floor,Stockton,CA 95202-2708 JAN 10 2011 the 12'h of each month <br /> Adephune,(209)468-3420 Fut; (209)464-0138 111'eb.www.sjgov.orgkhd <br /> c'' SEPTAGE CLEANERS REPORT ENVIRONMENTAL; Eggs <br /> PERMIT/SER;Compuny Name. CReport for mon <br /> Company Address: 04 Signature: <br /> Strecl Address y 'Lip Cade�{��� <br /> ti -A <br /> All Infnrmntinn viibmilted must be ram leie, accurate and le Ible J <br /> 0) DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (Rl RESmRNTIAL <br /> `' PUMPEDi�I2DPE32'I'YOIYI\E12 PUMPER (C) cRL18Zrwtr NAMEOFTREATIMEN'r <br /> 101.8AHE INCLUDE STR£ET .X, DIRECTION, STREET' NA,1IE AND CITY i~ CHEMICAL FACILITY <br /> co <br /> CV <br /> � Cit <br /> 0 <br /> LV <br /> cily <br /> City <br /> City. <br /> City <br /> City <br /> Cit <br /> City <br /> City k <br /> City <br /> / City <br /> City <br /> Q City <br /> tv <br /> City <br /> Q , <br /> ('ity <br /> cu Oty <br /> c2 <br /> Cil• <br /> e-- <br /> ck <br /> 0 <br /> Cite <br /> C <br /> 171111,I�•Ilr•al L1 Cn-H-n`.,...•..-moi u..-... <br /> 8-,tt1'UII•I <br />