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* REC I V EC <br /> JUN 112014 <br /> SAN JOAQUIN COLWY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL HEALTH 1216Retof this form h the <br /> C4 12 of each month <br /> CO 1868 East Haze#ton Avenue, Stockton, GA 95205-62321'ERMIT/SERVICES <br /> 0 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www_sjgov.org/ehd <br /> z SEPTAGE CLEANER'S REPORT <br /> Report for the month of:� C! year <br /> rte: Company Name: <br /> v, Company Address: s Ga rpco e::!a�]" Signature: <br /> streak Add esi <br /> 0 <br /> All lnlormatlon submitted must be com lata accurate and legible <br /> j` Q9 �loemAt NAME OF TREATMENT <br /> DATE NAiAE OF 6U3WE330R ADDRESS WHERE WORK WAS DOME GALLPUPPONS <br /> Kai e�AmTKAP FACILITY <br /> cr PUMPED PROPEITTY0%%7R PLEASE INCLUDE STREET • DIRECTION STREET NAVE AMD CITY tm <br /> ��� <br /> E <br /> Nagha w <br /> T � - � I <br /> Zr2tve _ <br /> f 9 �`► a C - <br /> 3 <br /> CRY <br /> CRY <br /> f� <br /> c1 C-1 <br /> �D <br /> C- o <br /> z <br /> Cit <br /> Q <br /> rn <br /> m <br /> city <br /> F— <br /> U <br /> C <br /> e> o <br /> Vi <br /> G <br /> C <br /> 'Q CE <br /> e <br /> a <br /> Yc Page of <br /> SEPTAGE CLEANERS REPORT <br />■ ■ ■ ■ ■ 12-04 <br />