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t�rN SAN JOAQUIN COUNTY <br /> EmvlRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street,Stockton, CA 95202-3429 72'h of each month <br /> T'elephoes:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br />� 4 <br /> 4 ' " SEPTAGE MEANER'S REPORT <br /> Company Name: ��t'tiU!)'7 (,�G f - Report for the month o ; /UCLIPJ 'year <br /> C-1 Cam paYlyAddress: 2S' cJ ;nd s �°� 93G11� Signature: /�G1vr� <br /> ca SIMI Address City Zip Coda <br /> C5 All Information submitted must.be complete, accurate, and legible <br /> AL <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS iR? *U'8'0T <br /> NAME OF iYiF,ATlHEHT <br /> PUMPED PROPERTY OWNERPUMPED (G) cREMET ap FACILITY .• a <br /> PLEASE INCLUDE STREET 4, DIRECTroN, STREET NAME AND CITY C CHEMICAL <br /> c (A qsno' <br /> v G7 -5 04 1 GO 21 W �W' 01 68 SZ3 `7 <br /> /09 !1 r1If 4 5 cry i1J -Al co U CRY 0 <br /> aU U r (A M 6 c� ( c 0 �5z <br /> c "M& CAI Z w ' Cvv `7 c' C) S 2� <br /> Off <br /> city <br /> c• <br /> Y <br /> City <br /> Q <br /> Chy <br /> 2 <br /> C <br /> City <br /> city <br /> OD <br /> a <br /> c <br /> © <br /> SEPTAGE CLEANERS REPORT <br /> EHO 42-04 <br /> 1014107 <br /> • II <br />