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RECEIVEDSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENTp O Return this form by the <br /> a JAN 05 2011 COO East Main street, Stockton, CA 95202-3029 12e'of each month <br /> Telephone:(209)468-3420 Fax:(209)4640138 Web:www.sjgav,FrglehW <br /> ENVIRO NTAL HEALTH SEPTAGE CLEANER'S REPORT <br /> Company Name: PE I Report for the mo h year,0l0_ <br /> Company Address: ,�- �jca Y �y �; /«lo _ Signature: <br /> Stlee!Addmss Cep 74p Code <br /> oo All Information submitted must be complete. accurate and legible <br /> m DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE CALLONS tR) mmENTIAL NAME OF TREATMENT <br /> 0 + PUMPED PROPERTYOWNER PUMPED (G) GREAsETRAP FACILITY <br /> + PLEASE INCLUDE STREET S. DIRECTION, STREET NAME AND CITY (', CHEMICAL <br /> d .+ <br /> ~ ` C <br /> RY <br /> city <br /> C" <br /> cily <br /> city <br /> Gftv <br /> coy <br /> C" <br /> C' <br /> C' <br /> city <br /> C <br /> E <br /> O <br /> eft <br /> L� <br /> Q cfty <br /> M C <br /> Q1 <br /> m CRY <br /> rI <br /> cft <br /> m <br /> fU <br /> i <br /> EM 42-04 <br /> z 1WW07 SEPTAGECLEAMERSREPORT <br /> CE <br />