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RECEIVED <br /> CSD <br /> a—I 14RQd•,,rA <br /> SAN JOAQUIN COUNTY SEP 11 <br /> 2078 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue Stockton. CA 95205-0232 ENVIRONMENTAL H Return this form by the <br /> w °°' a K lefephone: (209) 468-3420 Fax:{209)464-0136 Web:wwW.sJ90v•orgJeh�JERMtT/SERVJ�E � of each month <br /> SEPTAGE CLEANEB'5 REPORT <br /> Company !!lame: <br /> Company Address:— ;?al _/ may) / -7 Report for the m h o • year <br /> Street AddressCiy Signature: ti <br /> 21p Code /e <br /> Alf information submitted mtf�,t be com fete, accurate, artd 7D ible <br /> DA-IE r4AME OF BUSINF-SS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE (R) RESIDE DIAL <br /> PLEASE INCiUDrr SIRE ET :i, DIRECTfor4, STREET NAVE AND CITY GALLED NAATE OF 7REAM ENT <br /> PUMPED �O) GREASE TRAP <br /> H CA 7 Y {C} CHEMICAL FACILITY <br /> Cn <br /> ciI r. yg qvo c <br /> Llir• <br /> f <br /> � 8.3d �• � Cit <br /> O ! / <br /> 0y .4, !lr�c S C y•. Cit i-y"wc <br /> 00 O d .v <br /> C iI V r� <br /> / ' / d' ✓4 Oil f Cit <br /> /f cdy C. <br /> c n O Al <br /> 1..4 01 Of /tGir I�.G S Gil <br /> cit <br /> Q <br /> N <br /> M <br /> L CI d <br /> m <br /> N Ci o <br /> cv <br /> Cit - <br /> Ifl T <br /> CEJ <br /> CD <br /> cry <br /> co <br /> m <br /> N <br /> PHD 42-04 Of <br /> m <br /> 12!2?Y#3 <br /> m <br /> 6 EPTAGE GLEANERS REPORT <br />■ ■ %■ ■ <br /> ■% ■�■ <br />