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SAN JOAQUIN C=OUNTY <br /> ENVIRONMENTAL HEAi.TII DLPARTMF,NT ,�/3�/�� Return this form by <br /> 1 <br /> 600 East Main Street, Stockton,CA 95202-2708 �yuM�` the 121h of each month <br /> t Telephone:(209)468-3420 Fox:(209)464-0138 Web: www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> a Company Name: �uv-\ va Report for the month of: year�0 13 <br /> Compauy Address: S , fle•r MJ 0 Signature: <br /> $tree(Address % City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF MISLNESS OR ADDRESS WHERE WORK WAS DONE GALLONS �I RFs lAl. NAME OF TREATMENT <br /> V) PUMPED PROPERTY OWNER PUMPED (G) UREASE'1)(AP FACILITY <br /> Cl) rLEASF. INCLUDE STREET N, DIRECTION, STREET NAME ANI) CITY (C) CHEMICAL <br /> rD cif <br /> O <br /> O <br /> City <br /> N <br /> (fit <br /> Ckh C5 <br /> V ` city <br /> city <br /> City <br /> Cit <br /> cit r <br /> Cit �^ <br /> 0 <br /> Cit z <br /> Q I <br /> vtp <br /> _.. <br /> CitySEP <br /> Q Cit 2Q� <br /> m 1 <br /> A m <br />- cit P n fE T o <br /> m Cil Rjq^F5+ "' i <br /> C- <br /> - <br /> City <br /> - Cit —� <br /> m � <br /> O Cit <br /> N — F - <br /> O <br /> _ Citya� <br /> M a <br /> LO Cit a� <br /> CD <br /> a� <br />��■% 42-04 Septic/Cesspool Report <br />