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�D <br /> SAN JOAQUIN COUNTY <br /> MAR 0 3 1010 ENVIRONMENTAL HEALTH DEPARTMEW ,Return this form by the <br /> 600 East Main Street,Stockton, CA 95202-3029 92�'of each month <br /> 1RUITA IV T HEALTH Telephone:(209)468-3420 Fax:(209)4640138 Web:www.sjgov.org! dENT I �`"°"""' <br /> C � 3 <br /> PERMIT/SERVI SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the year,!V <br /> I <br /> - <br /> Company Address; D - ! Signature: <br /> Stns,Addles City Z q Code <br /> 03 All Information submitted must be com 1®ta accurate, and legible <br /> i <br /> DATE NAME OF BUSINESS OR (R) R"ENnel <br /> ADDRESS WHERE WORK.WAS DONE GALLONS NAME OF TREATMENT <br /> � <br /> PUMPED PROPERTY OWNED IR PUMPED (O} � ' FACILITY <br /> PLEASE INCLUDE STREET 2. DIRECTION, STREET NAME AND CITY (ClCNUMAL <br /> FG- I C <br /> City <br /> i <br /> Ckv <br /> j <br /> CRY <br /> Cite <br /> Cdy <br /> CRY <br /> i <br /> CiN <br /> LL C" <br /> 0- <br /> cu <br /> I <br /> f? CRYa <br /> fU <br /> CRY <br /> it <br /> fU <br /> rn EM 42-U <br /> 10!4(07 SEPTAGE CLEANERS REPORT <br /> C= <br /> J <br />