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a n9 aZ SAN JOAQUIN COUNTY RECEIVE <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton,CA 95202-3029 JA1J 1 2 2019 12U`of each month <br /> .+ I Telephone:(209)468-3420 fax:(209)464-0138 Web:Wsnv.sjgov.orglehd <br /> a ppSEPTAGE CLEANER'S REPORT ENWRONMENTALHEALT <br /> Company Name: // /l/�i siy ��/ `/p« j �Q �' PERMIT/SER—ICFrt$ / <br /> Report for the mon year <br /> Company Address: Signature: <br /> j street Addmss CM ZZP Code <br /> All information submitted must be complete. accurate, and legible <br /> m DATE NAME OF 13USINESS OR ADDRESS WHERE WORK WAS DONE GALLONS IRI REsmENTIAL NAME OF TREATMENT <br /> m PUMPED PROPERTY OWNER PUMPED (GI CREASE IRM FACILITY <br /> PLEASE INCLUDE STREET r, DIRECTION, STREET NAMIE AND CITY C CNEMIAL <br /> UO <br /> 0 <br /> cty <br /> F- <br /> c <br /> ( <br /> city <br /> OfE <br /> CE <br /> city <br /> city <br /> N <br /> r <br /> 9 <br /> N EHD 92-04 <br /> N ID/4/07 SEPTAGE CLEAVERS REPORT <br /> N <br /> 6 <br /> ti <br />