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SAN JOAQUU1(;GUNTY <br /> ENN'MONMENTAL HEALTH❑EPAR-rmENT Return this farm by <br /> ` <br /> 600 Ewt Main Su 1,StmictoN CA 45202 270$ <br /> �. � ENTLiR > �of each month <br /> TeCephoaer(204)468-3420 Far(209)464-013$ if'cb:w'ww'.sJgov.olg/ <br /> SEP #U CLEANER'S REPORT - <br /> Coi perry Name: Report fort ma pr: I I r veer <br /> 06 <br /> Company Address: ft.lt 3�r�O'k) 3igDature: <br /> StlCcl As)�ti3 sty zipcok <br /> All durormaliao Iubulitled be Complete, resuralc and legible <br /> DATE NAME OPBUErNESSOR <br /> PUMPED PROPADDIRM WHERE WORK WAS VOnE GALLONS �I prams rriAL NAME OFTREATMCHT <br /> UTI'01 Ncit PUMPED (G1 CREASC7RAP RACkLiTY <br /> INCLUDE STREET M, DIRECrICN, STREET NAMt AN}1 CITY G CIIZFSI <br /> �3"d8 PLEASE I17 1 r ,Zi /Sao <br /> r R,ZOv �- <br /> 6 <br /> Ch. <br /> my <br /> ------------- <br /> Alp <br /> — Ow tu <br /> MAY <br /> a . <br /> CI <br /> D <br /> Gil <br /> city <br /> ENVIRON <br /> e• <br /> CliR 42-94 <br /> __ SgdiQ Cwugool RepW <br />