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1 .. <br /> SAN 6:�I.,.Y}'ivyyW lire ASO VI�t1�1,! 1 <br /> ENVIRoNmEmrx HEAL.'I IDEPART[WENT Return this fe rin by the <br /> i } 9868 Easy Hazelton Avenue, Stockton, CA 95205-6232 1P of each month <br /> `elephot eo(209) 468-3420 Fax (209) 464-0136 Teti:wwvv.sjgov,,org/ehd ,. <br /> SEPTAGE CLEANER'S REPORT <br /> O�y��,Ea��y Name: '� � � �? - _ Report bv the month of: �)n )year <br /> � �51�'g���rr7i! ���9�:�31•eSS: �� � ':\� ��r 1�4� � ���,.,�� �(�l;,t,'' '%) i:� � �., �.�,;:� ���n�ta���e :, 1 - �-,;� " <br /> Street Address` CRY -' Zip Code <br /> A111 Information submitted must be complete, accurate and legibleROSID <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (Gl GRgA PT A6.Ap NAME OF TREATMENT+ <br /> PUMPED PROPERTY OWNER PUMPED �m1 oRSAs> rnFACILITY <br /> I <br /> PLEASE INCLUDE STREET A, DIRECTION, STREET NAME AND CITY C CNEh91CAL, Y <br /> 4X ;_ L .� cn Uj �, <br /> City <br /> cit ��• <br /> Cir <br /> cit <br /> City1 <br /> City <br /> city A, <br /> cuv <br /> C� 1y <br /> city <br /> city <br /> city <br /> Cit <br /> city <br /> Cit <br /> city <br /> city <br /> Cif 1 <br /> ® <br /> ENO•t2-04 SEPTAGF_CLEANERS REPORT' <br /> 1014107 <br />