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SAN JOAav(N COJNT <br /> Return this form by the <br /> EWIRONM�ENTAL FIEALT-Fi DEPARTMENT 92'° of each rnontn <br /> 6D0 East Main Street, Stockton, CA 952D2-3029 <br /> w 4 OCT 10 2017 <br /> �^ def hong: 209 46B-342D Fax: 209 454-0138 Web:www-sjgov.orgfehd <br /> ENVIRONMENTALHEALTH SEPTAGE CLEANER'S REPORT <br /> P ITISERVICES _ � - <br /> ^~ca� 'j ��, ,� lr I r. � ..���'' a Report for the month of: year <br /> Company Name: <br /> � c,,� <br /> P / <br /> Company Address: /� f� j . ! 0 Signature: <br /> zip Code <br /> Street AddmdM CRY :/ r!✓ <br /> All information submitted most be cocci fate, aocurats and le lble IRj Nt�IIEpFTREATINENT <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORX WAS DONE GALLONS F _'G} GXLEASETTus i FACILRY <br /> f= PLl'ypED PROPERTY OWNER ►LEA5E INCLUDE STREET f, QtRECTLOM, STREET WAME AMD CITY C C*EY2(JtL <br /> ��� 1 i %,��V� "l/j I '�f� L ��(-/ry� �� �d "� �r� 1 6 <br /> CL V1 <br /> cow <br /> H <br /> 9 <br /> v <br /> citj <br /> v <br /> r• <br /> D <br /> N <br /> City <br /> C?tY <br /> D <br /> V <br /> T <br /> SEPTAGE CLEANERS REPORT <br /> E'-O 42-04 <br /> f <br />