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I--� EDO <br /> SAN JO,AQUIN COUNTY Return this farm 6Y <br /> o `��;h e ' �0�8 EN- IRONME1�NTAL HEAL'rfl DEPARTNTENT ENTERED Lb <br /> N =` ` � 304 East 1�L''eber Avenue, ?`�Floor,Stockton,CA 4524?-2708 the lZ afeach month <br /> Ogg" Telephone:(209)468-3420 Fax:(209) 464-0138 Web:,,vwwslgov-arg+ehd <br /> SEPTAGE CLEANERS REPORT f� <br /> Report for the maath f_ year " <br /> Company Name: <br /> Company Address: S1 Signature• <br /> sfr�i Addre;s city Zip coag <br /> All iniormatiot submitted must 6e com lett atcoraf e, and to ible (R) RFSmUMAL <br /> ADDRESS�LIIi�RE WORK WAS DONE GALLONS (G} GarASETRAP NAME OF TREATMENT <br /> DATE NAME OF BRJ51NE55 OR FACILITY <br /> PUMPED PROPERTY OWNER PUhIPE11 <br /> PLEASE [,ryCLIJPC STIIC�"t d, �IAECT7Oti, 57gRCT NhR16 AND CITY (�E,UJGxL <br /> C[l' <br /> City <br /> City <br /> i <br /> Cin• <br /> City <br /> cam• <br /> 0h• <br /> City <br /> Coy <br /> r s <br /> eny <br /> ti <br /> rx <br /> city. <br /> r, City, <br /> N <br /> M <br /> N City <br /> Com' <br /> Q <br /> LL <br /> i Cry <br /> N <br /> 00 CLI• <br /> O <br /> co Citv <br /> O <br /> O <br /> ` "rt, <br /> r <br /> � Cr ly <br /> M <br /> a <br /> SepuclCc�yt:oi Repuri <br /> F F D 42-iia-009 <br />