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5 <br /> ti <br /> 9 SAS!JOAQUIN COUNTY <br /> 9 EWARONMENTAL HEALTH DEPARTMENT Return this form by the <br /> Eo0 East Main Street, Stockton, CA 95202-3029 12'�`of each month <br /> Telephone:(209) 468-3420 Fax:(203)464-0138 Web:www.sjgov.org1ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Gompany Name: Report for the month of: 4e t year U� <br /> Company Address: J ' SOX „7 qV e Signature: aO>��✓ ,�' <br /> Slmat Address City Zip Code <br /> All tnforrnatinn submitted must be-com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DANE GALLONS (R) Resmsvra� <br /> (q GREASE TW ttAMEOFTREATMENT <br /> �1MPED Pi20PEFZTYOWNER PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY PUMPED (Cl <br /> CkEMICAt FACtLJTY <br /> w ; City_ <br /> 3 <br /> city <br /> W <br /> I j city <br /> <=I <br /> 3 <br /> C <br /> co <br /> iryW <br /> I city <br /> 11 FEI} <br /> citv <br /> City <br /> citv <br /> C;t NM NTS HEAcityL <br /> city <br /> � f <br /> CD m <br /> LID city <br /> LE-) <br /> vCO Ci <br /> - � <br /> m cityo� <br /> city <br /> CV C <br /> Cn � <br /> m Cit <br /> a <br /> E <br /> — <br /> ,-a t-- <br /> t9 <br /> cV <br /> city <br /> an <br /> — <br /> a� <br /> m EHQ 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 9OW07 <br />■ ■ 01 ■ ■ <br />