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' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 013 600 East Main Street, Stockton, CA 95202-3029 12th of each month <br /> Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.sjgov.orglehd <br /> ' b t SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the mopth of: yea D/3 <br /> Company AWdress: - 7e Signature: <br /> Street Address Cd}r Tip Cade <br /> OD All Information submitted must be'complete, accurate, and legible <br /> 1-4 DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS tR) RISioENr1AL NAME OF TREATMENT <br /> © PUMPED PROPERTY OWNER PUMPED (1) GI-A.SF TRAP FACILITY <br /> PLEASE INCLUDE STREET t, DIRECTION, STREET NAME AND CITY C CHOW-AL <br /> V <br /> O (r city <br /> 1— <br /> CRY <br /> city <br /> City <br /> City <br /> city <br /> city <br /> City <br /> C' <br /> cr <br /> C_ty <br /> m <br /> 0 <br /> city wcm� <br /> 1 Q <br /> C M <br /> O <br /> • m <br /> cityo <br /> � <br /> city C-4 <br /> r <br /> L1 city <br /> Q � <br /> 01 <br /> city <br /> c- > <br /> LD _— <br /> ryl Ci a <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 1014/07 a� <br /> ■ ■ ■ ■ ■ <br />