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a' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street,Stockton,CA 95202-3029 Ith of each month <br /> a" <br /> Telephone. (209)468-3420 Fax:(209)464-0138 Web.www.sjgov,orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Y I Gt' ! C <br /> Report for the month of: C!1✓; yearR.�O 4! <br /> Compainy Address: C) Crl 3 �� Signature: v ye- S <br /> S4eetAddmss city zip Cflde <br /> CD All Information submitted most bs complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE FIGALLUMPED <br /> ONS (R) REsoEnAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER E (G1 � � FACILITY <br /> f._ <br /> PLEASE INCLUDE STREET �t, DIRECTION, STREET NAME AND CITY <br /> tc ur�u5jar� (�J'a/ C / «9 <br /> 1Y&7 h1AA USI e ? CR <br /> C <br /> ofty <br /> CRY <br /> crdy <br /> CRY <br /> city <br /> CRYQ <br /> w C4? <br /> a <br /> rn <br /> cly <br /> Ci <br /> rn <br /> 0 <br /> Q <br /> CRY <br /> C <br /> w <br /> a EHD 42-04 <br /> 1N4107 SEPTAGE CLEANERS REPORT <br />