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D ECE V ED <br /> t y ZOW SAN JOAQUIN COUNTY <br /> '- FEB 0 � � <br /> ENVIRONMENTAL HEALTH DEPARTMENT d rTE Return this form by the <br /> ci ENViROWENT HEALTH <br /> .a -EALT H � � oSeoj� 3s23 � 1 of each month <br /> pfflMfTJSERVECEjp►one:(ios)as� 2Fax (2sas¢o webwwwsjgov.orgh=hd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the month of: year,;2Q/0 <br /> Company Address: . p _ Signature: '07�� <br /> Skw AadMss �:7. City ZP Code <br /> 03 All Information submitted must be comp lets, accurate, and le Ible <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> PUMPEU)DD PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREAfINENT <br /> c PLEASE INCLUDE STRfE7 t, DIRECTION. STREET NAME-AND CITY <br /> PUMPED (�))-CHEAGM FACILITY <br /> F <br /> C <br /> City <br /> Cft <br /> CRY <br /> C <br /> city <br /> City <br /> city <br /> C-fty <br /> O <br /> lY .. <br /> CE <br /> C <br /> My <br /> <a <br /> 1D <br /> m <br /> [l.l <br /> (1! EK0 42-04 <br /> m <br /> 1Q/4lQ7 SEPTAGE CLEANERS REPORT <br /> W <br /> LL <br />