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m `�' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> m 1868 East.Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> a ''+t Ba Telephone: 209 468-3420 Fats; <br /> 1 (209} 464-0138 Web:Wv'w,sj90v.orglehd 12'' of each month <br /> <I <br /> SEPTAGE CLEANEli'S REPORT <br /> Company Name: <br /> s Report for the mo of: Dv yeas p?Q�/� <br /> Company Address: ;767/ �v eo,e IQ <br /> stree(Addreas - � Signature: <br /> 9 Zip Cade /C, L <br /> Afl information submitted must be com lets accurate and le ible <br /> DATE NAUfIE OF;U1 ;SSRPUMPED PROPERADDRESS WHERE WORK WAS DONE GALLONS {R} RESJ,,,,IAL <br /> PLEASE INCLUDE STREET K, DIRECTION, STREET t(Ah1E AND CITY I.C') GREASE TRAP NAME OFTREAMENT <br /> PUil4PED {C) CHFAUCAL FACILITY <br /> s5 " <br /> CI Q 4W6 <br /> J f&�sr r GH. // /x/97 Yc� <br /> lY <br /> Ci <br /> O <br /> oC< m� CilZX <br /> 'e er o, (� S <br /> <I City <br /> rY a o,`•c S <br /> Cimk <br /> 0 <br /> C� r� <br /> Cil - <br /> _ o <br /> Cil � <br /> N C-4 <br /> V Cil m <br /> m .o <br /> V <br /> CV CI <br /> u� o31 <br /> o� <br /> NCI o <br /> r <br /> Cif <br /> LO <br /> N a <br /> CD Cif <br /> CID . <br /> 1-i Cif <br /> m <br /> IN a <br /> Pa e <br /> EHD 42-N <br /> 12127/1 a <br /> C'4 v <br /> SEPTAGE CLEANERS REPORT � <br /> ■%MM%M <br />