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SAN.IQAQLiY RECEIVE <br /> ENVIRONMENTAL HEALTHALT'TH DEPARTMENT etlirll this farm by the <br /> 600 East Main Street, Stockton,CA 95202-3029 2�'of each month <br /> <' Telephone:(209)468-3420 Fax <br /> (209)4640138 Web:www.sjgov.org/ hd <br /> SEPTAGE CLEANER'S REPORT <br /> MY 09 2011 <br /> Company Name: iJ ReFOMRD% year <br /> Company Address: • v- O k 7 gigna [iM1T/8 <br /> Sheet Address My Tp Code <br /> All Information submitted must be cam tete accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS JR) NAME OF TREATMENT <br /> m PUMPED PROPERTYOWNER PUMPED (G) wMe11w FAgLITY <br /> C CN <br /> t <br /> PLEASE INCLUDE STREET i, DIRECTION. STREET NAME AND CITY EMIGIL <br /> lD <br /> O <br /> C <br /> H <br /> city <br /> C <br /> city <br /> C' <br /> cfty <br /> CRY <br /> Cft <br /> CRY <br /> Coy <br /> city <br /> 0 <br /> th My <br /> LL <br /> Cr <br /> re) Citym <br /> aty <br /> ri <br /> 1 <br /> e-1 <br /> C <br /> EHD 42-04 <br /> 4 1W4M7 SEPTAGE CLEAVERS REPORY <br /> Cr7- <br />