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SAN JDAQUIN COUNTY <br /> &MRO»MENTAL HEALTH DEPARTMENT Return this form by tfte <br /> 6D0 East Main Street, Stockton, CA 95202-3029 <br /> w .12t° of each month <br /> a Tefephorre: (209) 468-3420 Fax:(209)464-0138 Web:www.Sj90v.Dr91ehJ <br /> a !d1i <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: +� I 1 k(M/, I� Report for the nth of: I year D <br /> Company Address± U (. l Signa re' <br /> M.W Addw ca zip c, <br /> All iaformatlon aebmitted most be com late, accurate and legible <br /> GALLONS (R) .NAME OF TREATMENT <br /> DATE NAME OP BUSINESS OR AOD7tE55 WHERE MiWRK WAS DONE K;MPED 1G} aeEwiErnu FACIUTy <br /> l- PUMPEO PROPERTY OYENER (LEASE INC LCe! Si REEL r, CIR ECT tO M, aTA!ET MANE AMC CITY <br /> Q <br /> L'iOZ1313 city <br /> u X51.3155 vtficarv�1 00� <br /> 0 CAY <br /> IQ <br /> 3 ivii <br /> cry <br /> 7 <br /> 3�15 rJ <br /> cft <br /> cift <br /> a <br /> Ck <br /> ti <br /> 9 <br /> P <br /> D <br /> P <br /> T <br /> D <br /> N <br /> CAY <br /> cibf <br /> •V <br /> CSN— <br /> Uy <br /> SN <br /> n <br /> y <br /> SEPTAGE CLEANERS REPORT <br /> Ew a=a. <br /> 10 7 riNVIRDkb1ENTALHEALT:H <br /> PL4WAITIS ERVICECS <br />