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SAN JOAQWN COUNTY 17- 6P <br /> EmERtOMINTALHEALTH DEPARTMENT' <br /> PARTT <br /> m n Return this form by a <br /> a 344 East Wetter Avenue,3' Floor,Stocktbo,IyA 95242-2708 the 124 of each month <br /> n m Telephone: (209)469-3420 Faz:(209)464-0139 Web.www.ajgov.crg/ehd R, <br /> V <br /> S <br /> K-�� SEPTAGF CLE�� 'S REPORT <br /> i a ti�r � �lr �r <br /> Company Rome_ Report far 1� th onth of: ye„-�L <br /> Company Address: 2Z�i, �Oa. _ i ���( Signature: <br /> 9trm Adinp �1)- ZFc.& <br /> All Iotorm Rtioe submitted must 6e tOe late ■ttorule, Rod Ir iblt <br /> DATE NAME OF 13USINESS OR ADDRESS A)IMM WORK WAS DONE GALLONS C; <br /> �'�N'us' <br /> PLWEB PROPERIVOWNER (G) cAEAtt TRAP NAMEOFTREATMENT <br /> r LEASE INCLUDr STAErT N, DIRECTION, srArcT NASEC ANI CITY Ft�t�D FACILUT <br /> a. <br /> 1 VMy S <br /> OtT 2 <br /> w <br /> Cz- �.W , <br /> )2 (� DO c) <br /> O y <br /> a <br /> l <br /> 0 0 • o <br />� I <br /> o. `'CRY V <br /> N . un ZU(� <br /> e p. <br /> Mao <br /> r <br /> SJDLO ci, <br /> c2no <br /> b F- z <br /> h -CRYn 0' d <br /> Nfl Lltr <br /> D r <br /> wn <br /> D -} v I� <br /> m� a., +L s o <br /> OYv <br /> 7 <br /> N/ Lib <br /> P9 4L-32. c* a <br /> o <br /> � o E <br /> NJ � <br /> nq <br /> NERD 42.04 > <br /> m' 8/30104co <br /> la <br /> c <br />