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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this forn by the <br /> Cv 600 East Main Street, Stockton, CA 95202-3029 <br /> 12e`of each month <br /> CL Telephone: (209)468-3420 Fax. (209) 4640138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: C5;-Z.) Report for the month of: year <br /> Company Address: y <br /> Signature: <br /> Simet Address C:rLv Zip Code 0 <br /> All Information submitted must be tom plets, accUrate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NANCE OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) r-w-ASE-FRAP FACILITY <br /> C <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> A 77 <br /> jj ,(��j T CHEMICALl 22-c- fi2 57 Inc, <br /> pek�-r C4y <br /> Ci <br /> C4, :5 <br /> 6 (A-' <br /> CRY <br /> -5 j r< r S LIU r- <br /> 4 0 S <br /> ._Cly X311;52 <br /> o7ty�' 5F3s-- C1y 5 Jry Z:A Lf f'r <br /> A Coy S <br /> C"Y. <br /> -4," 1,4 aly <br /> CHY 5 m r -;-e- <br /> /A <br /> IL <br /> C"' C-/Z s. J-'C t <br /> ^t rrlU �T`rSh Stq2 RC. <br /> oly .5 Tr'e- C'-� "ac <br /> Civ -57 0,14c, -rc� 1:33&�z AZI <br /> cty 5 <br /> - <br /> EHD 42-D4 Ar, C'y <br /> IWVD7 SEPTAGE CLEANERS Fi=-PDRT <br />