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SAN JOAQUIN COUNTY <br /> z �Wc F'NvrunNm-PNTAL HEALTH DEPARTMENT Return this form by <br /> jS Street,Stockton,CA 95202708 the 12'k of each mouth <br /> Telephone.(209)468-3420 Fa (209)464-0138 Web:www.sigay.orgehd <br /> tr <br /> a4 q P <br /> iFa N SEPTAGE CLEANER'S REPORT <br /> `, <br /> 'L Company Name; 1 C ( i ! } <br /> Report for them th of: ? year <br /> 1.Company Address: a,oLoLL2q gtmL � ��~. y f Signature: goy :t hfit✓?fit t��t <br /> Svaz Address zip code <br /> All information submitted must be complete, aecurate, Sed legible <br /> DATE NAME OF BUS]NESS OP ADDRESS WIMRE WORK WAS DONE GALLONS (R) R£SmElVTUL TAME OF TREATIvMXT <br /> PUMPED PROPERTY OWNER PUMPED (G) GxeAsE7ltAr FACILITY <br /> PLEASE INCLUDE. STREET #, DIRECTION, STREET NAME AND CITY (t;) CHEMICAL <br /> `4(tc�{t vt 6�—X(-}i'�s - c �t Yc1ty '�.f !` (`?� ( I �u l� i �,(:%t CP <br /> y,,r.� � <br /> i 1 lJ J :rC {fL 2 City 'l�,cs <br /> 0('wv�� &q Mq =t 51 i C city <br /> g Nut <br /> Si 6 • ci `7 o� r��r� ��1i�� 117M, �. ��-v`� ICU L i gg� l:..aci �" c_c .. �`? %2- <br /> 'Ytu � C� <br /> N yracity t 7:: r c;zv / 1 . I L1 y�,o �; c <br /> � cG �,4 GNU,- Ar(N- 1A 2-2 6 5i C,yf- <br /> �isC".jj <br /> LY5 It <br /> ii <br /> �T N ;.,lLw 6 aye— c;N I ra cc, `-Tt�'Cr1 (,i ao 1 MEE <br /> Q <br /> 0 t t5�cli ti ati� . <br /> cit" i-r :Z 'v` { etc• LtlC'r i�, <br /> )., ., c (raIra 00e <br /> L o <br /> !?� Q LA cx ,5'1 rl-6 5 . Pec-WIsM R�6 a �; � L <br /> f�%' t� � ��,. �� •.-- �{.Lfi;t� Cha, lt�C} -� <br /> `-1•�(l t'�bt 2.t� f air ,tt;in�� I�c�?�-� �, .`� .`� .1� C;� � <br /> )"t&-li -surk 11 i _ j4 <br /> CA S <br />°' <br />� UID Q-04 <br /> D_ ... 5cpticlCessvool Report v <br />:%%%* <br />