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SAN JOAQUIN COUNTY <br /> J. rN !A N E A1HEALTH DEPARTMEAIr Return this form �ythe <br /> � <br /> 98G13East Hazelton Avenue, Stockton, CA95ZnS-6232 12th of each mr'u>Ihl <br /> Telephone:(209)468.3420 Fax:(209) 464.0998 Web:www,sjgov prg/ehd <br /> tsv EyPIR"0GE \✓krn�,nANE�T,S R�.yP�MMRr� <br /> 0�'Ompany Name. � !1 CCL �'l 2 O �C" Re�r�r��s the manta o'Y: e�lk�� <br /> il <br /> C,',ompany Address: .._ C' c 1 H Signature, <br /> M IV01 Aditlt <br /> A91 nfo �4 °�! _ m;�tt�d YYI t bd aom etca..,-- u° s�4n,r d <br /> DATE NAND OF MUSINESS OR MUMS WHERE WORK WAS DONE GALLONS (R R130I139NTIAL NAME QP TASATMGNT <br /> PUMPED PROPMRTY OWNER PUMPSd (0) ORSAs8 TRAP FACILITY <br /> _. .._.._ PLLASE INdLUDB 9TR<3R7' 01 DIREOTION, OVAUDT NAME AND OITY L i0lOHS 04L <br /> 1"..-'...'1.^.n-...._-..._' .":C.^..._ '._��........�.;S. T..t....�..'^�ytY."..Y. <br /> , 1 <br /> CIl <br /> C <br /> ,i <br /> att <br /> CIt <br /> Oily <br /> Gk <br /> .......�...,,,,". _..."...._.._..�_.._,..._..... 1711 <br /> CIIV <br /> - <br /> O I <br /> j <br /> O1 xl I <br /> Clip II <br /> ti <br /> CI "` <br /> I <br /> city, i I <br /> �,_ _....._... _.._._.. .� . Q& <br /> I <br /> Cr II�4 <br /> D E PA I2T M E N C <br /> FUD 42.0+1 �\f� r � �/](�� (�(�� � �� � - � SE"P AGE Cl.iANtrRS REPORT <br />