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RECEI-' SAN JOAQUIN COUNTY <br /> EilVIRONMENTAL HEALTti DEPARTMENT <br /> �w Return this form by the <br /> 600 East Main Street, Stockton,CA 952D2-3029 <br /> 12th of each rnorAh <br /> d Telephone:(209)468-342D Fax:(209)464-0136 Web:www_s19ov.org � 2 13 <br /> CL <br /> REPORT <br /> SEP7AGE CLEANERS ENVIRONMENTAL �0 <br /> m �C) )N L .-L l (� Repur '1 h4�brr3$ T <br /> 1 '`" ear <br /> Company Name: <br /> Signature: <br /> Company Address: v car o <br /> sv�L aaa,r,n <br /> All inforrnatlon Submitted must be core fate, accurate and le lble NAME OFTREATMENT <br /> OR PUMPED( <br /> ADDRESS Yif M WPMPED <br /> ORK WAS DONE PUgtEAsa <br /> DATE NAME Qf Bt)SIf�iESS FAC1L17Y <br /> J PUMPED PRDPERTYO11W1ER /LEASE INCLUDE STREET t, WRECTLON, STREET WANE AND CITY CMEIhCJtI ' <br /> = I� <br /> I <br /> Q �? <br /> H <br /> T <br /> L 7 <br /> 0 Ck <br /> � Ltt► <br /> _T <br /> W <br /> ck <br /> 011y <br /> C. <br /> C <br /> llJ " <br /> r4 <br /> @ <br /> Q <br /> l0 <br /> Q' <br /> CV <br /> city <br /> M <br /> e-a <br /> H <br /> CV <br /> OJ <br /> CJ SEpTAGE CLEANERS REPORT <br /> `-r EHD 42-04 .. <br /> tOJ4JD7 <br /> I ' <br />