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ex 4 _ SAN JOAQUIN COUNTY <br /> Return this form b the <br /> ENVIRONMENTAL HEATH DEPARTMENT Y <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12' of each month <br /> Telephone:(209)468-3420 Fax.(209)464-0136 Web:vMVi.sfgov.orgleha <br /> SEP AGE CLEANER'S REPORT <br /> Company game: t� ! Report for t e mo th of, year (7 <br /> Company Address: �*— U s ,6 Signature, <br /> Street Aftiress Zip Cod`- <br /> All information submit:?o must be corn lete, accurate and legible <br /> DATE NAME OF BuStESS OR ADDRESS WHERE WORK WAS DONE (R) RESIOEM1RiAL <br /> GAf10NS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUrAPEl1 (0) cpxAsrma, FACILITY <br /> PLEASE INCLUDE STREET S- DIRECTJON, STREET [JAME AND CITY (C) CMEMAL <br /> y- ' rcwo <br /> S r c <br /> r 1 c� l 1 o�(�b 2 L? <br /> j � gI 1 Gil <br /> 4 cS- ti <br /> 3� <br /> t cu <br /> z <br /> IJ <br /> mU <br /> o2p 4 G ,24 600 <br /> r_ <br /> city <br /> I <br /> G <br /> 2017 G <br /> ENVIRONMENTAL HEA,M city Page a# <br /> EVD 42-04 SEPTAGE CLEAN ERS REPORT <br /> 12127113 <br />