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m <br /> RECEIVED <br /> JAN 0 9 2017 <br /> �Pr�qulM s SAN JOAQUIN COUNTY <br /> Ld <br /> ENVIRONMENTAL HEALTHEtdVIRONMErFTAL HEALTH DEPARTMENT Return this form by the <br /> IPERMIPSERVICE� <br /> � ;; - � 1888 East Naze(ton Avenue, Stockton, CA 95205232 12U' of each month <br /> Telephone: (249)46B-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the nth of: 0 year <br /> Company Address; Q= y Signature: <br /> Skeet Address Cfly Zip Code <br /> All information submitted must be cum tete, accurate, and legible <br /> ) DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RF_SIDIR IAL VVE OF TREATNI ENT <br /> PUMPED PROPERTY OWNER AGI GRFASETRua <br /> PUit1PED FAClIJTY <br /> <I PLEASE INCLUDE STREET k, DIRECTION, STREET NAME AND CITY GHEWCAL <br /> 3 <br /> W <br /> co CiI <br /> _Q <br /> Cfl <br /> W <br /> <I <br /> r <br /> Ci <br /> city <br /> Ck <br /> LSl <br /> chy m <br /> 0 <br /> cityo <br /> z <br /> city <br /> m CC) <br /> IC) } <br /> city <br /> In <br /> V C8 <br /> OD r` <br /> m <br /> m o <br /> N <br /> city C-4 <br /> CI � <br /> city <br /> N - � <br /> CVV <br /> Ca <br /> m <br /> N <br /> � C <br /> m Page. 0f <br /> ■ ■ ■ :H`42-C4 SEPTAGE CLEANERS REPORT a <br /> ■ ■ ■ 0 ■ <br />