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I I 4 S <br /> SAN J4AQUIN COUNTY 5 <br /> ENVIRONDaNTAL HF.ALrH DEPARTMENT Retarn this form by y <br /> 341 Fast Vlcber A�euue,3`d Floor,Stockton,CA 95242-2748 the 32tn of each month <br /> Telephone:(249)468-3420 Fac:(209)464-0138 Web,www.sjgov.org1rhd <br /> t SEpTAGE CLEANER'S REPORT �s.�,�, o <br /> Company'Name: e, <br /> Report for t� mantle of: year— m <br /> Company Address: It ZSignature T <br /> Sped Zip Ad& s Cep] <br /> 0 <br /> All information sabmiifed mnsi be corn fete, accurate, and legible <br /> DATE N,lhiE OF BUSf3 GS5 OR ,ADDRESS WHM %'YORK NNAS DONE GALLO l-S G) Sxs�sa�RAr NAME OF TREATMENT <br /> PUNTED PROFERTY OWNER , YUMPED FACSLTPY m <br /> P1.GA5£ 1NC1.l.DE STREET e, DIRECT10;1, STREET NhhiE hTD CITY CH6hiiCAt. � <br /> a <br /> civ <br /> 0 00 e) e f <br /> Citv <br /> & <br /> ti• )/ City l <br /> /r tt <br /> .ti } <br /> cry /1 tit l �. <br /> ar-a <br /> CityXA <br /> IL <br /> -)r�b$ ��— —JJ� G5- <br /> 4t �l <br /> IV <br /> r/ <br /> ' 909 City <br /> a <br /> ciry g <br /> c ls• <br /> a <br /> 4- <br /> Ci ry <br /> - <br /> cir <br /> EHD 42-04 <br />