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SAN JOAQUIN COUNTY <br /> Etd RONMENTAL HEALTH DEPARTMENT Return this form by the <br /> CD 600 East Main Street, Stockton, CA 95242-3028 12th of each month <br /> w Telephone:(209)46&3420 Fax: (209)464-0138 Web:www.sjgov.orgfehd <br /> i SEPTAGE CLEANER'S REPORT <br /> 0- <br /> /- <br /> Company Name: �Lf 7`li.� Report for the mpnth of: _ .12 C� year 4 <br /> Company Address: -Ja Jz a�� Signature: <br /> Street Address CRY Zip Code <br /> All i.nformatia.n submitted must be com tete, accurate, and legible <br /> SATE NAM&OF BUSINESS OR ADDRESS WHEREWORKWAS DONE GALLONS {R) RESLMNnAL NAME OF TREATMENT <br /> JrdPED PROPERTY OWNER PUMPED (G} GREhSE7RAP FAC9ATY <br /> PLEASE INCLUDE STREET V. DIRECTION, STREET NAVE AND CITY C C{MWlCAL <br /> Uv - C <br /> lY <br /> W Cil <br /> 3 <br /> W city <br /> U1 <br /> `L <br /> city <br /> 3 _ <br /> co city <br /> W <br /> `L <br /> C-Ity <br /> } <br /> C <br /> rn <br /> " o <br /> , City <br /> z <br /> a <br /> City <br /> m � <br /> L0 <br /> Ln Ci <br /> OD L-C" <br /> T C- <br /> city <br /> m o <br /> N <br /> C <br /> 0 <br /> Uj <br /> cityz <br /> i9 <br /> a> <br /> City <br /> cAtym <br /> CV � <br /> CV > <br /> I— EHD 42-04 <br /> SEPTAGE CLEANERS REPORT a' <br /> m <br /> 1U"7 u <br /> IN 0 0 0 0 <br />