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RECEIVEDSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> APR 0 8 2011 600 Fast Main Street, Stockton, CA 95202-302; 12th of each month <br /> a: Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.s <br /> ENV1ROW,J NTA ESLTH SEPTAGE CLEANER'S REPORT W, J �J <br /> Company Name:PER"iI 2` -f' Report for them of: year <br /> Company Address: -�- Signature: <br /> Stmt Address cily 23p code <br /> Ib All information submitted must be complete, accurate, and Ie Ibis <br /> M <br /> [TATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS iR} R —'� NAIVE OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED I�1 GREASE FACILM <br /> PLEASE INCLUDE STREET /, DIRECTION, STREET NAME ANO CITY C CW-HICAL <br /> Ct <br /> 17 <br /> 0 city <br /> CRY <br /> city <br /> c' <br /> CRY <br /> city <br /> c• <br /> CRY <br /> 0 <br /> IY <br /> vCft <br /> CRY <br /> of <br /> m <br /> r, c <br /> ftvm <br /> CU <br /> El-D 42 W <br /> m I(V"7 SEEPAGEGLEA!R5 <br /> IFREPORT <br /> 0_ <br /> Q <br />