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SAN JOAQUIN UOUNTY <br /> 0,+ ?�� f(� ���J�j��I} �j ENV1RONMFNTA1,F EALTII DLPARTME,NT Return this forst by <br /> 600 East Main Street,Stockton,CA 95202-2708 the 121v of each month <br /> Telephone,(209)468-3420 Pax:(209)464-0138 Web:www.sjgov.0rg/eIid <br /> GO 8 <br /> ' PUMPING SERVICE SEPTAGE CLEANER'S REPORT <br /> II�U� w�^ ' �DEBRABORREW t �Y <br /> CL Company Nat F _ Report for the, onth of: ) yearl(T_ <br /> Rl.00K,GA 1 <br /> Company Address: Signature: 1 <br /> Street Address Clly 7,ip Uncle .��31 <br /> V <br /> All inforroatiuu Subuliltcd must de complete, accurate, and is iMe <br /> DATE NAME Or BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) Rr.S11)rNT1AL NAME OF TRIIATDIF.NT <br /> Lr) PUMPED PROPERTY OWNER PUMPED (G) CR AP fACILYTY <br /> ce) PLEASE INCLUDE STREET is, DIRECTION, STREET NAML AND CITY (< <br /> (9 <br /> (9 LI IV A F5110i <br /> City <br /> Citv <br /> N <br /> Cit <br /> Cif <br /> City <br /> J2 L LA <br /> y <br /> city <br /> 1 <br /> r <br /> City <br /> Cit <br /> Cit <br /> (. City <br /> O <br /> m Cit <br /> r City <br /> m <br /> W <br /> Q <br /> city <br /> Cil <br /> tts <br /> N Cit <br /> O <br /> O <br /> r.;f <br /> CO <br /> 0 <br /> v ICit <br /> 0 <br /> CU r•.lm 42-04 Rptic/cesspool[report <br />