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i <br /> SAN JOAQUIN COUNTY l lJ <br /> M ENVIRONMENTAL HEALTH DEPARTMENT etU1 n1his form 4y.the <br /> 600 East Main Street,Stockton,CA 95202-3029 �y j & 200 f <br /> Telephone.(209)468-3420 Fav(209)464-0138 Web:WWw.sjgov.o ! h <br /> SEPTAGE CLEANER'S REPORT ENVIRONMENT HEALTH <br /> Company Name: �' �1i(1AA <br /> At-%lv ,�/'diC ReAw"kMqu _c_ year 05 <br /> Company Address: s+r�A � t10 M t lclkdreW �Ld�r�P� z l 14,�Slgnature: !''4.af <br /> All Information submitted must ha complete. accurate and l0 Ible <br /> E` DATE NAIVE OF aUSINESS OR ADDRESS WHERE WORK WAS HONE GALLONS {R) �� NAME OF TREATMENT <br /> N PUMPED PROPEWY OWNERPUMPED {fly GREASE TRAP FACUM <br /> PLEASE fNCLUDE STREET i, DIRECTION, STREEr NAME AND CITY C eFk"YICAL <br /> � 6 u <br /> / 90 nAa <br /> o City <br /> M <br /> LO c' <br /> L city <br /> w <br /> In <br /> C <br /> city <br /> 9city <br /> - <br /> E <br /> 3CA <br /> a <br /> c' <br /> 40 city <br /> c <br /> tU <br /> city <br /> E <br /> C <br /> LOCw� <br /> C C. <br /> W <br /> city <br /> CRY <br /> Ln C' <br /> N <br /> N C <br /> O Cily <br /> 07 <br /> O <br /> EMD 42-04 SEPTAGE CLEANERS REPORT <br /> fU <br /> iN4Nt7 <br /> U <br /> 0 <br />