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SAN JUAQLTtN C(KWff c, <br /> C4 ENY[RONAfENT'ALBrALTH DEPARTDSE1,17' L(hc12 <br /> this form b}' <br /> 304 East Weber Avenue,3i/Hoo,Stockton,CA 95202_2708a, <br /> 9r at each month <br />�m <br /> Telephone:(204)468.3420 Par:(209)464-0138 Web:wwW.sjgov.Org/elld a <br /> 9 <br /> SEPTAGE CLEANER'S REPORT <br /> ia Company Neme: _�l\ Report for the nth of: year <br /> Company Addrss: �xL�( �{'1� At. �W i t ��i4� I��� Signature: <br /> strsn AJan, aqsp rd. <br /> All information submilled meat be roI lett Attu rv(e, And legible <br /> DATE NAME OF BUSINESS OR ADDRESS VWM WORK WAS DONE GALLONS (R) ACAIDIKnAI' <br /> KIMM PROPERTY OWNER lG) ck A TRAv NAME OF TREATMENT <br /> PLEASE INCLUDE STREET H, DIRECTION, SrA[rT NAME Ati® CITYPlllvlPED uy PAC11d1Y <br /> my 2 <br /> a so 2 my 2 <br /> w cm <br /> jw �,ti� C.r <br /> O <br /> Oo <br /> o" 2>1 I <br /> o • ary' a <br />& ) � 2 N <br /> 'I lzfoaw S� CCN 33gZ r <br /> /b an r . <br /> I <br /> cry. �., <br /> 0 <br /> Y 1ae <br /> «o 0 <br /> z <br /> p I L,J a. MINI: <br /> n o <br /> ry9 yb S. cMIwo �• u <br /> MT <br /> °s 2 LSn J000 G N <br /> mZinn <br />" o S 2CO S. \N. <br /> 30 <br /> msL a,y <br /> D <br />.r„ � r as <br /> J t IP o <br /> NI N <br /> N <br /> J o <br /> N, HID 42-04 a '— <br /> mJ 8130/04 <br />� d <br /> m � .� 4 <br />