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REcavaj. <br /> 13 2011 <br /> SAN JOAQUIN COUNTY SAI"r-k <br /> a ENVIRONMENTAL HEALTH DEPARTMENT PERMn, Return this.form by the <br /> 1868 East Hazeltgn Avenue, Stockton, CA 95205-6232 12th of'each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:,www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: J 2Q /qy / C� (�r S'/�� Lt�Y/ i�l/C Report for the anth of:QMb9it year Q 0 <br /> Company Address: ,/3 7C�� �l r_ . 'T/ 7T7_� , �'� Signature: <br /> Skeet Address city ZIP Code <br /> All Information submitted must-be complete, accurate and legible <br /> DATE NAME•OF BUSINESS OR (R REs1oENTIAL <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT. <br /> PLEASE INCLUDE STREET A DIRECTION STREET NAME AND CITY PUMPED CN CALV FACILITY <br /> city <br /> e` <br /> 5 U6� �' 1/Z%N 5 / �1� Ct �� � �• 1 <br /> cit <br /> W•NL 0 s&s 2605 . 4#4) cit <br /> r l t/ 5 i N �Q y� 2tJ• �i' l� �9�/T cit i ;< < <br /> fiv5eWODo B041WCA�II S Sot TM .5-elk0e -$T city 6-0L 1 i t) <br /> cit // .. OJ 1 I <br /> i t MILL y Til/l� l L l3 �' �uAPil city <br /> % ' 1 U L" c�>�"; G'9�i/� city <br /> city <br /> r33 LAW)- city / t• L. 1 i r <br /> 0� 1 ��I �i9STli�� i7�9/✓ <br /> city <br /> city <br /> l�il l�I v 1 /SSD G✓ ST f�i rfw �� cit <br /> cit <br /> I �La� ,zn -n7l 142' S� /y' Ul2ti' ,rJ &Wd <br /> Page , of <br /> EHD 42-04 <br /> 12127/13 SEPTAGE CLEANERS REPORT <br />