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a 2O SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> N�N� 600 East Main Street,Stockton,CA 95202-3029 �,... 12c'of each month i <br /> EN����N��S�pt�'C�•�Jellaphone:(209)468-3420 Fax:(209)4840138 Web:www.3190v.0rgl' <br /> r pERM SEPTAGE CLEANERS REPORT <br /> Company Name: h V f Q✓1 Report for the month of: j year Q <br /> Company Address: �a I 6 to G1 Signature: <br /> Street AAdmas Zip Code T �� <br /> All Information submitted must bs complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE OALUDNS lRl ReslDEatttaL NAME OF TREATMENT <br /> PUMFED PROPERTY OWNER PUMPED tot OREM TRW FACILITY <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME ARD CITY (Cl-CHEMICAL <br /> N <br /> 0/3L,) L W&J Op #}c7U5 70D 5 EG 5T C' Ixk r:. E ,t. <br /> r~ <br /> Cftv <br /> r <br /> C <br /> n7 C' <br /> LID <br /> L <br /> w <br /> N <br /> � t <br /> C <br /> !Z <br /> E <br /> d <br /> c <br /> ro c <br /> V <br /> C <br /> w <br /> E <br /> chy <br /> :> city <br /> W <br /> rAtu <br /> C <br /> 07 <br /> Ln <br /> O <br /> Coy- <br /> SEPTAGE REPORT <br /> EHD 47-04 <br /> p 1014707 <br /> r <br /> 07 ' <br /> 0 <br />