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- <br /> m SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form b <br /> 60D East Main Street, S1Ocldon,CA 95202-3029 y the <br /> o.i Telephone:(209)465-3420 Fax:(209)464-0130 Web:www.sjgov.org/ehd I2 h of each month <br /> a <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �;. �/� Yll I h (J R�Q <br /> Report for the month of: A r i year°Z_ G^/� <br /> Company Address: V . i i, ��,, CG 2 c� h i �� q i y]' <br /> slce4 Addlas ��� ,`� gnature• /% i,/I_s � <br /> Zip Coo r <br /> All Information submitted must be com Tete Accurate. and le Ible <br /> GATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE (R) "SIDENTAL <br /> = PUMPED PROPERTY OWNER 6AlLONB NANE OF TREATMENT <br /> f— ((Lyn <br /> PLEASE INCLUDE STREET 4, pIREC TI/O/R, iTREET MAME ARD CITY PUMPED (e) UREASE Tom' FACILITY <br /> W L4 I (Wy illi D CREMCFL <br /> To <br /> c4 <br /> c <br /> U E1VED <br /> D <br /> ` MAY 15 2012 <br /> D <br /> ENTAL <br /> c <br /> PERM I SERVICES <br /> ce <br /> D C <br /> n <br /> y <br /> D <br /> r <br /> D <br /> 1 r' <br /> J C <br /> C <br /> I <br /> i G <br /> Cn <br /> CO <br /> EMD 42-04 <br /> VQW07... <br /> SEPTAGE CLEANERS REPORT <br />