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1:^ t <br /> R o SAN JOAQUIN COUNTY � <br /> 1=.NWRONMV-NT.AL HEALTH DEPAR'f v*NTReturn this forirl 6y 1� <br /> 3U4 Fast weber Aveulie,3[d Flaar, Stockton,CA 45202-270$ � � :he 12i&ofeach month o <br /> Telepljone:(249)468-31420 Fax:(209)46,1-0138 I.Vvb: www.sjgov.org:ehd m <br /> SEPTAGE CLEI ANTE R'S REP0RT <br /> Company Na in c. � Reportiol "1 01111, 11 � year ozCJv� � <br /> CornpanyAddress: 7 w s9, Sigaa#�ire, <br /> Stre-[rLddrt City Zip Cale a <br /> a <br /> 1 <br /> All intarmafinu slabutilieil Itlu9t be caul elrie, accurate, and ]s i4Je � <br /> a� <br /> DATE 1.017 OF BTJSMi SS OR ADDRESS�i'NFRt_A,0R1C li'AS nd`1L+ GALLOWS �'j nEslol n-rl,sL <br /> (Q G)IEASET1w, NAME OT TREAThTLTl+ T <br /> 1`uh1p1,1} Pit 4OPEATYOWNER PLEA3P (Ncr.u),r 5TJ4EET V, R)RRC'I'JON, STREUT NAME AND CITT 1'1MVIPED 1�ACILTPY a <br /> -_ (C) C71E\TICAL � <br /> Cu}' QJAO Jj t ea <br /> Oty <br /> City <br /> ci[y <br /> ci n' 000 <br /> my c�ly <br /> Cil7 r L/l./ .., `k 1 <br /> K— r <br /> City + <br /> cir a' <br /> f "4 ' <br /> m <br /> Cil}• <br /> as <br /> Citi y <br /> 6 cily i e <br /> Cily <br /> City 1 <br /> 0 <br /> City <br /> v <br /> 0 <br /> Cary I o <br /> j ry <br /> 1 \ <br /> O <br /> CIS , N <br /> .. 'ICJ �1 <br /> 1 <br /> OD <br /> oily ao <br /> City <br /> AHD 42-04 <br />