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RECEIVED <br /> f AUG 0 7 2015 <br /> SAM JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> '• ENVIRONMENTAL HEALTH 600 East Main Street, Stockton, CA 95202-3029 120 of each month <br /> < PERMIPSERVICESTelephone:(209)468.3420 Fax:(20 9)4640138 Web.www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT / <br /> Company Name; Report for the month of: < l� year <br /> Company Address; y li ,� �/ Signature: , <br /> Street Address city Zip Code <br /> All Information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR (R) FmsjD@�7ML NAME OF TREATMENT <br /> i ADDRESS WHERE WORK WAS DONE GALLONS (G} cRaasE TRAj. <br /> i �PAPED PROPERTY OWNER PUMPED FACILITY <br /> PLEASE TNCLUDE STREET C, DIRECTION, STREET NAME AND CITY C CHEWCAL <br /> rI <br /> Ld <br /> 3 C <br /> W <br /> F— <br /> <-L <br /> Cit <br /> 3 <br /> Co City <br /> Lu <br /> � Cih <br /> } <br /> Cify <br /> al <br /> Ci C—' <br /> o. <br /> Cit o <br /> z <br /> l _ <br /> ( <br /> city <br /> (9 LC') <br /> LID <br /> Ln <br /> v <br /> G7 L <br /> 0� <br /> ED p <br /> N city <r <br /> C f� <br /> N <br /> C� Q <br /> 19 <br /> citya� <br /> E <br /> city <br /> I9LEE] <br /> m > <br /> V E1O 42-04 u <br /> m 1 a14J07 SEPTAGE CLEANERS REPORT � <br />