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■iiii■ <br /> ■ ■ ■ ■I■ <br /> SAN JOAQUIN COUNTY <br /> Y '4` ENVIRONMENTAL HEALTH DEPARTMENT <br /> Return this form by the cn <br /> r..: <br /> a' <br /> 600 East Main Street, Stockton, CA 95202-3029 72 of each month m <br /> Telephone:(209)46S-3420 Fax:(209)464-0138 Web:tivww.sjgov.orglehd I- <br /> SEP AGE EANER`S REPORT <br /> Company Name: �' !tel`7 d LQ C:�� / Report for th Gnth of: a'C year ,,n/j (A <br /> w <br /> Cornnan Address: )7? Ltak Signature: Ae- e- <br /> Strezlkl&ess Coy Zp Cede <br /> vi O <br /> All information submitted must be complete, accurate, and legible 3 <br /> _o DATE NAME OF 13USINESS OR ADDRESS WHERE WORK WAS DONE GALLONS lRl RESDEWTIAL NAME OF TREATMENT � <br /> PLWED PROPERTY OWNER PUMPED lo) FACILITY D <br /> PLEASE INCLUDE S1REET /, DIRECTIOY, STREET NAME AND CITY C ME-AICAE H <br /> �l <br /> 5 D <br /> z 4 / eco 3S/r/ A cam-- 36! J w7 r <br /> 0 Me o <br /> 0 <br /> ti <br /> CAy <br /> Cky <br /> CD <br /> w <br /> ClY <br /> 0 <br /> ctyF, <br /> Rl <br /> cly <br /> ` m <br /> I � <br /> city <br /> Q� <br /> .A <br /> m <br /> C1 <br /> 0) <br /> C <br /> City <br /> r <br /> EHO 42L4 SEPTAGE CLEtYERS REPORT <br /> 1 WC,'o7 <br />