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RECEIVESCD <br /> SAN JOAQUIN COUNTY <br /> FEB 0 4 2015 <br /> m ENVIRONMENTAL HEALTH DEPARTMENT Return this form bz e <br /> Li _ 640 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www-sjgov.crglehdUIIT�;F <br /> L F SEPTAGE CLEANER'S REPORT <br /> Company Flame: V,--; z z Report for the month of: C year 20-Dr <br /> Company Address: ,-2, Signature: , <br /> Street Address City zP Code <br /> Arr informatran submitted must b© complete, accurate, and legible <br /> DATE NAME CF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS {� 1211elTiaL WME OF TREATuENT <br /> BUMPED PROPERTYOWNER PUMPED (G) GFREASETRAP FACUTY <br /> PLEASE INCLUDE STREET i, DIRECTION, STREET NAME AND CITY C CF{73S}CAL <br /> CY <br /> W city <br /> Q <br /> W cfty <br /> U <br /> <L Cif <br /> 3 <br /> co ity <br /> LLd C <br /> Cad <br /> city <br /> city <br /> c7t � <br /> C-4 <br /> C CO <br /> 0 <br /> C z <br /> v Chy ¢ <br /> tD <br /> 0 <br /> Ll) <br /> C o <br /> v <br /> co Cl <br /> S <br /> CD o <br /> N cr <br /> d <br /> city <br /> N <br /> L0 <br /> City <br /> a <br /> m , <br /> Ci, a� <br /> LC) E-Z <br />-4 <br /> m Cit 1— <br /> N a <br /> City <br /> a� <br /> V <br /> CD <br /> a� <br /> N U <br /> 9 EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10W07 <br />