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SAN JOAQtIm COITM <br /> vv EMILItONMENTALHEALTT3 DUAKTA'IENT Return this form byUl <br /> � <br /> mfl 344 East Weber Avenue,3"'Floor,Stockton,CA 95202-2708 the 12th of each ruonth <br /> OD Telephorte(209)468-3420 Fox:(209)464-0M Web: ArwA,-sjgov.org/chd Q <br /> wa SEPTAGE CLEANER'S REPORT 2 <br /> <I 3 <br /> �L Company Mame: UK <br /> � r� RcpQrt fflr the IIia af; ytar <br /> Comp2ny Address: 2Z C [.t/��S Signature; <br /> &rcct Ad&au C% lipCadc <br /> All (nformaiian submitted moat be cora Ittc accurotc, sod legible <br /> fR1 ssst>FTnr1Ai. <br /> DATE NAAIEOF19USIM1ESSOR ADDRESSM'IIEREWORKWASDONE GALLONS tG) cn�Ast� NAMEOFTIEATMENT <br /> P'DMPFdl PROMI(TVOWN€R . s1EAst INCLUDE STAtET e, DINICTION, SIRECT RAMC Aho rM, PUMPLID C93AncAL FACILM <br /> (Yly <br /> cily S,V�!1 <br /> wZ :32/ City co <br /> Cn <br /> (� ` ko <br /> 0O 7 43 Clly 1G. V c <br /> CII <br /> Cloy <br /> In <br /> city <br /> -"fGv • <br /> YYcil <br /> z <br /> �o m <br /> r,m <br /> Q1.-1 � Crq' M <br /> In m <br /> Lnv <br /> LO LO <br /> � V, <br /> ZVI <br /> _ //�/y� M <br /> Ckv .J Wt:/�. , <br /> CV N �J o <br /> U at4 - a <br /> CO <br /> LS 04 <br /> L o <br /> " <br /> t0 - City �{� r ¢ <br /> m ClayAJC ! 1 N _ <br /> C'4 C4 <br /> CD <br /> `c EHD 42-04 <br /> m m L-Y <br /> 8/30104 � �, <br />