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yl SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton,CA 95202-3029 12N of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.orglehd <br />° -y- SEPTAGE CLEANER'S REPORT <br /> Company Name: ��l 1"6a Report for the mon ,/ �� year ?0/ <br /> Company Address: //- d-A0y 7S�Cl ///�� rpt //� 95��6 Signature: <br /> Sheet Address CM Zip Cuda <br /> All Information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS IRI RESID�TtAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) OREasETRm FACILITY <br /> -� PLEASE INCLUDE STREET P, DIRECTION, STREET NAME AND CITY C CHRWAL <br /> IT <br /> kDD <br /> City <br /> O <br /> ~ C' <br /> City <br /> REACEIVED it C <br /> city <br /> CRY <br /> city <br /> ENVIRONMENTAL HEALTH <br /> PERWHSERVIGES c' <br /> Cityrn <br /> m <br /> c <br /> 0 <br /> t <br /> CRY <br /> � cCRY <br /> I <br /> c' <br /> r <br /> o <br /> Cdy <br /> �. C <br /> ayV <br /> Ua) C o <br /> �I <br /> coycrty <br /> � <br /> 91 <br /> fU <br /> rld <br /> mN � <br /> ' EHD 42-04 SEPTAGE CLEANERS REPORT <br /> + 1014/07 <br /> M%■a f0 <br />