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I <br /> --j SAN JOAQJlN COUNT'y <br /> o DiVIRONMENTAL FJF-ALTH DEPARTMENT Return this form by the <br /> 6DC)East Main Street, SlocMc)n, CA 95202-3029 1z' of each month <br /> LIJ <br /> -bidTefe-phu":(2 09)46R-3420 Fax:(209)464-ID1 38 Web:www.sjgov.c>rgfehd <br /> SEPTAGE CLEANER'S REPORT <br /> Repoli for the itit of. year <br /> Company Name: <br /> Signature: <br /> Company Address: "Kt'� LJ- ✓ Zip Code <br /> All information submitted most be cvnipl,.ate. accurate and leqlble- (R) <br /> ADDRESS WHERE W03kK WAS D014E GALtows NAME OF TREATWNT <br /> DATE NAME OF BUSINESS OR FUNPED GREASE TR" FACILITY <br /> fcl <br /> PUWED PRDPERTY OWNER PLEASE INCLUDE STREET V CIREC110M, STREET NAME AND CITY CSIEMrJLL <br /> <1 <br /> c4iy <br /> T <br /> ql <br /> 0 <br /> Lj <br /> CAY <br /> cit., <br /> OD <br /> C414 <br /> CD <br /> lz <br /> tD city <br /> (S) <br /> CV <br /> City <br /> c4l, <br /> C* <br /> A <br /> 47 <br /> C'4 <br /> OD <br /> G) <br /> SEpTAG+-CLEANERS REPORT <br /> C-4 <br /> EYID 4z-04 <br /> 10MID7 <br />