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SAN JOAQUIN COUNTY <br /> z EwRONmr:NTAL HEALTH DEPARTMENT Return this form by the <br /> { 6110 East Main Street, Stockton, CA 95202-3029 1P of each month <br /> Telephone:(209)46&3420 Fax:(209)464-0138 Web--www.sf go,r.orglel�d <br /> SEPTAGE CLEANER'S REPORT <br /> Comparty Name: �f'G�M!//�1 a ckmoi x;_,e - Report for the month of: ' C year n <br /> Company Address: _•�� 6�1� �/,TO 2cz s C.4 l 3�J�. Signature: R ./ ICZ. 7!7/7 ,j ye--r <br /> Q <br /> $Ueatnddress car rp Code <br /> o All Information subrnitted must be complete, accurate and legible <br /> z <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WDRK WAS DONE GALLONS (R) iwDENrIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY � • a <br /> PLEASE INCLUDE STREET N. DIRECTION, STREET MAKE AND CITY C, CHEMCAL �xAFW kv-1'n%11TM <br /> CRY <br /> cky <br /> c• <br /> ow <br /> city <br /> city <br /> CRY <br /> 4 <br /> CAY <br /> a i <br /> L ' <br /> car_, <br /> a <br /> city <br /> C <br /> a <br /> C3` C <br /> C <br /> rn <br /> g <br /> city <br /> a <br /> C <br /> U <br /> a EHD 42.04 SEPTAGE CEMERS REPORT <br /> 4014fp7 <br />