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-' qul, RECEIVED <br /> m ks e�A SAN.JOAQUIN COUNTY <br /> HEALTH EALTH DEPARTMENT <br /> OCT O 9 2 1Return this form by the <br /> 1868 East Hazelfan Avenue,Stock(:ort, CA 95205-6232 12th of each month <br /> "�;, a.�-� Telephone: (209) 468-3420 Fax:(209) 464-0138 Web:www-sigov.org/e'64VIRONMENTALtEA11W <br /> SEPTALGE CLEANEWS REPORT FIERMITISERVICES <br /> Company Name: � pJr�eF �lY <br /> s t for the t f: <br /> _ year o?�/ <br /> Company Address: i?pl J oSee-ro-� to > C <br /> , Signature: 1 <br /> Stree(Address city Y r <br /> Zip Code <br /> All information submitted must be complete, accurate and legible <br /> NARRE OF ELIS[NESS OR {R) JtESmENTIAt <br /> jDATE <br /> ) PED PROAERTy OWNER ADDRESS WHERE WORK WAS DONE GALLOKS NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DFRECTFOIJ, STREET NAME AN❑ C1TY PUMPED {G) GREASE TRAP FACILITY <br /> H � r�C /<4 Maya <br /> r // {C) CHF KCAL <br /> C.dII�r [{O� city119 C l <br /> 6 D Jvq <br /> Q Ci SOpDy, <br /> o dA <br /> IL CiF Yav C _ o <br /> C <br /> 0 <br /> CiI <br /> ciI <br /> 0 <br /> 0 <br /> ai n-, <br /> CF o <br /> z <br /> t` o: <br /> N � <br /> - <br /> m m <br /> ct <br /> N CH ! <br /> [n d <br /> m <br /> CD <br /> r <br /> Cit o, <br /> N CD <br /> CSD <br /> N <br /> M Page of <br /> CD EHa 42-b4 - <br /> m 12127(13 u <br /> SEPTAGE CLEANERS REPORT a <br /> ■ ■ ■ ■ ■ <br />■ ■ ■ ■ ■ <br />