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RECEIVED <br /> SAN JOAQUIN COUNTY <br /> 2Q111f ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> d Aut—'. 6CO East Main Street, Stockton, CA 95202-3029 12v'of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> IRONM NTAL HEALTH <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: !/Y /!i" M;,Jhly ,. Report for the month yearp?� <br /> Company Address:—� Signature: <br /> SIrtHAddrss City Lp Cada <br /> N <br /> rl All Information submitted must be complete, accurate, and le Ible <br /> © DATE NAME OF BUSINESS OR (R) REs®ENiIAL <br /> ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) OnP FACILITY <br /> PLEASE INCLUDE STREET S. OIREC TION, STREET NAME AND CITY C piEYKAL <br /> O <br /> F <br /> C' <br /> city <br /> C <br /> cay <br /> Ce <br /> City <br /> CRY <br /> C" <br /> C' <br /> C" <br /> cdy <br /> C' <br /> City <br /> E <br /> O <br /> of L" <br /> 11 , <br /> 0- C' <br /> !n <br /> N <br /> N C <br /> ti <br /> C' <br /> ti <br /> ti <br /> m <br /> crty <br /> fU <br /> i <br /> CP EHD 42-04 <br /> > 10;4/07 SEPTAGE CLEANERS REPORT <br /> O <br /> Z <br />