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m 00 :f*d, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street,Stockton,CA 95202-3029 12"of each month <br /> Te%phone:(209)46B-3420 Fax:(209)464-0136 Web:wvvw.sjgov.olglehd <br /> a \ � <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: l C 2(w(1 r)0 dam+ L (J b Report for the month of: per- year C'I I <br /> Company Address: P.0 . boy, 9Z7 �52,)M24eu, CA . 94fo3 SignatureIt"P7 <br /> Sliee A00rew city 21p C.& <br /> All information submitted must be ccm late accurate, and le Ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORN WAS DONE OALLONS {Rj REsrDE Oe" NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (OI MEMN E"UN, FACILITY <br /> BJH PLEASE INCLUDE STREET S, DIRECTION, STREET NAME AND CITY C CRES:AL <br /> Ii CA <br /> 2 <br /> Q CA <br /> f- <br /> Z CRY <br /> W <br /> cow <br /> Zf <br /> O <br /> K <br />> C <br /> ZW <br /> CRY <br /> C' <br /> CRY <br /> city <br /> CA <br /> m <br /> CO <br /> ED <br /> m <br /> LID <br /> c U11 <br /> Q = <br /> CD City <br /> N <br /> CRY ENVIRONMENT ulHEALTH <br /> N C <br /> N <br /> Coy <br /> gm <br /> 0 <br /> m <br /> ti <br /> N <br /> m <br /> N <br /> DsI <br /> COY <br /> EH04204 TT i\ InJ (3een (-)" D ea <br /> �o� <br /> SEPTAGE CLEWERS REPORT1014107 <br /> Fhe 1�4c�r� k ti o� Dc� . 02011 1oF. E�2( rIg2+-) ` E , C, (3 .C . <br /> (ot-tH0&)rL <br />