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-rq:' .R'�.G <br /> :,. <br /> i� San Joaquin County <br /> ..�..,.,.< Environmental Health Department Return this form by <br /> ��; , 3D4 East Web er Avenue,3rd Floor,Stockton,CA 95202-2708 the 12th of each month <br /> C-4 <br /> Telephone: (249)468-3420 Fax: (209)454-x138 Web:www.Agov,orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: UNITED SITE.SERVIGES Report for the month of MAY year 2011 <br /> Company Address: 360 N. 10TH ST SACRAMENTO 95814 Signature: <br /> o Street address city Zip Gude <br /> z <br /> All information submitted must be completed,accurate and legible <br /> (R) RESIDENTIAL <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (G)GREASETRAF NAME OF TREATMENIT <br /> PUMPED PROPERTY OWNER PLEASE INCLUDE STREET#,DIRECTION,STREET NAME AND CITY PUMPED ( C)CHEMICAL FACILITY <br /> 512V201'I MORADA FARMING 500 N JACK TONE RD crry LINDEN 404 C OMI THAMES WATER <br /> CITY <br /> a'rY <br /> CITY <br /> CITY <br /> CITY <br /> CITY <br /> CITY <br /> CITY <br /> "' CITY <br /> w <br /> CITY <br /> � CITY <br /> cn CITY <br /> a.. CITY <br /> CITY <br /> CITY <br /> CITY <br /> z cnY <br /> cmY <br /> cmc <br /> crry <br /> C rrY <br /> Cm <br /> C mr <br /> T C mf <br /> ctry <br /> C rrw <br /> CrrY <br /> cm <br /> cmc <br /> Crry <br />