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SAN JoAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street,Stockton, CA 95202-3029 12"'of each mornth <br /> CL Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> 4*1. . <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 41 o 5-1C C 1GfiL`F- Report for the month of: z-:;' Year z; O, � <br /> Company-Address: Q't '009Si g <br /> nature• -v <br /> Spee)Address City Zip Code <br /> All Information submitted must be cam late accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (RI RES�ENTIAL MAN E OF TREATMENT <br /> PUMPEO PROPERTYOWWER PLEASE INCLUDE STREET N. DIRECTION. STREET NAME AND CITY PUMPED tC;} GpFAseTkAP FACILIrY <br /> 7 G txENicAL <br /> � y <br /> t°1 fc1,c�C city5fcr�l�* c'!� 1 i c11r= <br /> '`JffYt1 IE.�114�'L�,^+ ��j}.rz rS- City -ft. rt,-t 6)'D <br /> Cay L C) <br /> 7C-7 a City (.t) i= <br /> c •S 7t trn <br /> r er-.ie 7of-1 S c v <br /> Stet A,' Pt: 44 CX S7e4r-f6--rC <br /> �-i J C rx eel�as �r..►. fX; f��-c.w &,.•-cmc. C-4 to -33f;Z,'l rL t c1 <br /> a <br /> G `f4C.— T7 C cit 7"C';'+ X33 v 2 5 cv f <br /> v im; yr ci <br /> Q - <br /> " -zs-lC IV •�.� f'. •I} i C t4 L�3c� �l cC �+' S !"cc t o� i GY �' IS <br /> a- )--4,,—S iA Li C f " - t j f �`r� c. 5 7`� C IGTz 0 LJ <br /> city <br /> ci <br /> Ci <br /> City <br /> city <br /> GI <br /> � C <br /> a Eof4D 42-134 SEPTAGE CLEANERS REPORT <br /> On <br /> a <br /> CS <br /> c <br /> N <br />