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SAN JOAQUIN COUNTY <br /> EwRONWNTAL HEALTH DEPARTMENT "um <br /> '18 form by <br /> bob East Main Street,Stoddon,CA 95202-2708 the 12"of each month <br /> ' Telephone.(209)468-3420 Fax(209)464-4138 Web.-www,sjg0v.argle� ENTEREt � <br /> R SEPTAGE CLEANER'S REPORT <br /> Company Name: f Report for the mouth of: year _ m <br /> Company Address: R�!. �� �,f5�� t�a �;6 r ��f� Signature: m <br /> Stred Address City Zip Code W <br /> All information subeeitled mull be cnm tete, accurate, and legible <br /> DATE NAME OF AUSR�ESS OR ADDRESS IWERE NVORK IWAS DONE GALLONS [R) x�vLVTUL NAME OF TR£ATMENP <br /> PUMPED PROPERTVOYMER PUMPED (G) FACFL]rYV <br /> PLEASE INCLUDE STREET k, DIRECTION, STREET NAME AND CIrY CREFLUC&L <br /> "Ic city <br /> -13 <br /> city 70M <br /> m <br /> 3 <br /> city C <br /> 3 <br /> O <br /> C D <br /> C) <br /> City <br /> r z <br /> { <br /> f <br /> aty <br /> ciy <br /> aty <br /> a <br /> c <br /> ck <br /> Oty <br /> City <br /> Cityw <br /> a <br /> to <br /> aty <br /> a <br /> ary0 <br /> 1) c ' <br /> :0 m <br /> Ci W <br /> G) <br /> w <br /> EFEi aZAA Seplic�Cesgpaa[�t <br />