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e+. SAN JOAQUIN COUNTY <br /> ENVIROmmENTAL HEALTH DEPARTMENT Return this form by the <br /> 800 East Main Street,Stockton, CA 95202-3429 12th of each month <br /> `• Telephone.(209)468-3420 Fax.(209)464-0138 Web:www sjgov. P <br /> xa� SEPTAGE CLEANER'S REPORT <br /> Company Name: IL Report for the month of: 5Pd yeaT _ <br /> cx:>, Company Address: �- CM Signature: <br /> r— StreLAAddress CRY Zip Code ' '1 <br /> o All IniormatilDn submitted must 6e com lets accurate and legible +-f <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) REVOENTrAt NAME OF TREATMENT <br /> PUMPED PROPERTYOWNER PUMPED tO� OREASETRAP FACILITY <br /> PLEASE INCLUDE STREET 4, DIRECTION. STREET NAME AND CITY C CHEMICAL <br /> f / &C'ty <br /> C" <br /> city <br /> C' <br /> city <br /> City <br /> city <br /> city <br /> C'dy <br /> Ci <br /> Ci <br /> x CI <br /> ( <br /> city <br /> city <br /> city <br /> rn <br /> ciky <br /> G' <br /> a <br /> q <br /> cily <br /> Cti <br /> C/l C'Ij] <br /> Cil <br /> 3 <br /> O <br /> z EHD42-04 SEPTAGE CLEANERS REPORT <br /> t014107 <br />