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SAN JUAQI.IDt COtWFYM <br /> ENVUONMIMAL HEALTH DEPARTMENT Return this form by N <br /> 304Eeal Weber Avenue,3r°1400r,Sto"LL,CA 45202-2708 the 126 of escl manth m <br /> Teleplmnc:(209)468.1420 Fdr(209)464-0138 Web:www.ggovArg/ehd p• <br /> m <br /> SEPTAGE CLEANER'S REPORT <br /> T <br /> I COmpaoy Name: I n( ,, 1 2A, Qj, as f2— Report fa r the month of•, y ha year w) 2 <br /> s <br /> Campa>IyAddrers: 42Z�S (1 ,�. gS20S Signature: <br /> Str Adp a aiy Iyfid. <br /> All Information su6ea11LEd must be r mrilete, mccaralet and 1[ INt <br /> DATB NAME OF HUSINffi5 OR ADDRESS WHERE(YORK WAS DONE GAfLONS (R) r[llOeNaAL <br /> M cREAseT1IAe NAMEOFTRRATMENIr <br /> PUK <br /> Pt4�8D PROPFRTYOWNER rLRAIC INCLUDE STRLET t. DIRLCTION� %I-RreT NAME AND CITT PED q®aW. PACILUT <br /> aI, <br /> 3 <br /> Oty <br />�i 1 <br /> M <br /> 0) as2 av SOv o <br /> ��� <br /> O! cvv W V P <br /> 0 <br /> Sk 1af <br /> 2, S . N <br /> 2 a� <br /> i2 C31�,,�,� mss . C�r C <br /> k - ce, C0 r2- �. <br /> LEA <br /> } ILL elvi I i 0,o, 220 - Cky <br /> No F10 <br /> bvi) 1 , <br /> m o <br /> N r <br /> S• AvLjow ra <br /> w <br /> 12/W UAL (.,nvccfj Sri 2 <br />�� 'V S� IG � � S k--J" S • <br /> r � <br /> n <br /> N E <br /> m� 3) rtI And � S <br />�^ <br /> mID <br /> Q ENT)42-04 <br /> mD 9/30104 <br /> m ,� <br />