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SAKI JOAQUIN COUNTY <br /> ° ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> { 600 East Main Street,Stockton, CA 95282-3429 121 of each month <br /> Telephone:(209)468.3420 Fax:(249)464-0138 Web:www.sJgov.orgle T i'0�P€ <br /> SEPTAGE CLEANER`S REPORT <br /> 9 <br /> Company Name: qe / e - Report for the month of: !fid ye r_ <br /> Company Address: D YJ60 r/1 rs ?j z Signature: S <br /> Sit Addn cay Zip code <br /> CD All Information submitted must be Complete, accurate and le Ible <br /> z <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS tR1 MIDENTeaL NAM E OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED =G'} OR ASE TW FACILITY � <br /> PLEASE INCLUDE STREET 4, DIR8C7[OH, STREET NAME ATiC CITY C CHRf<}CAl <br /> 710 11w c. D <br /> a Z r 'a elQtl <br /> 5 <br /> z-73 41 <br /> 7115 AM(A 7 a/ � w v ow AoA64SZ3 <br /> 7 U Ti !� I11J C Z <br /> 711�10109 <br /> 72 v 9 0 T M41 119-0 <br /> a U r-S OZY tl C <br /> 719*10 ee d/ 73-A- n z <br /> ILI O <br /> o 0 �r 6 <br /> 09 XjAA6G ZCKY <br /> ctty <br /> cftvCRY <br /> a, <br /> 1SEFTAGE CLEANERS REPORT <br /> 100!4!0714107 <br />