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/ 191x3 <br /> ' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 12ei of each month <br /> Telephone:(209)468-3420 Fax:(209)4640138 Web:www.sjgov.org/ehd <br /> a <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: /�1 1y (/1��� � JC Report for the on f:- yearc��2 <br /> Company Address: 4J /, 4 �GJ ��ti l� �sSignature: <br /> Steel Address City Zip Code <br /> All Information submitted must becomplete, accurate and legible <br /> DATA- - -NAME OF BUSINESS OR--- -------ADDRE55 WHERE WORK WAS DON IONS -(R) -NAME OFTREATMENT <br /> ;PUMPED PROPERTY OWNER PUMPED (0) cJ+EA5E 7RnP FACILITY <br /> i PLEASE INCLUDE STREET t, DIRECTION, STREET NAME AND CITY - C CHEMICAL <br /> l0 1 <br /> V <br />~ C' <br /> C' <br /> city <br /> C" <br /> C <br /> city <br /> city <br /> cfty0 <br /> N <br /> O <br /> i C. z <br /> city <br /> 0 <br /> cfty <br /> Guy <br /> O <br /> G cv <br /> r <br /> LLm <br /> LL Gity <br /> LI <br /> Q city <br /> UI <br /> n <br /> city <br /> d, <br /> ti <br /> City <br /> ti <br /> m a <br /> CU EHD 42-04 SEPTAGE CLEANERS REPORT -— <br /> m tarvm <br /> z�.�■ ■ ■ <br /> ■MMI MI MI <br />