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r-I <br /> CEIVED <br /> CD <br /> ' ° SAN JQAQUIN COUNTY ;U N 0 9 2015 <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> CJ' I <br /> Telephone:(209)468-3420 Fax:(209)464-•0138 Web:www.s19ay.Org1end IHEplq4LTH (2U'of each month <br /> SEPTAGE CLEANER'S REPORT <br /> CarnPany Name: <br /> _ Report for the nth of: ( _ year <br /> Company Address: �� -/,5 � C/�/.����r��� � �13� <br /> Sl reek Address Signature: <br /> 71p Coda <br /> All information su <br /> bmitted must be complete, accurate, and le able <br /> DATE NAME OF BUSINESS OR <br /> _ LIMPED PROPERTY OWNER ADDRESS WHERE'WORK WAS DONE GALLONS <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME ANO CITY PUMPF-D {G} GRErsE7RaP NAME OFTRFATMENT _ <br /> w CHEMICAL FACILITY <br /> <I <br /> Ld C <br /> U7 <br /> <I Ci <br /> 3 <br /> U� <br /> city <br /> W <br /> `I Ci <br /> } <br /> Ci <br /> C <br /> Ci o <br /> m <br /> Ci 001 <br /> r o <br /> (!D <br /> LL) <br /> I <br /> City <br /> u� <br /> v <br /> m <br /> m o <br /> N _ C-14C <br /> C' <br /> m <br /> ty <br /> N <br /> � a <br /> m -- <br /> � a� <br /> N EHD 42-04 <br /> U <br /> Lv TOW07 <br /> SEPTAGE CLEMERS REPORT <br /> ■ ■ ■ ■ ■ <br />