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RECEI01 <br /> SAN JOAQUiN COUNTY aturn this form by the <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w 600 East Main Street, Stockton, CA 952()2-3029 <br /> 12th o each month <br /> JAN Q 9 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.slg0v olrglehd <br /> _ SEPTAGE CLEANER'S REPORT ENViRD Edi T� II <br /> I � j Report far ear <br /> Company Name: nn - ,n <br /> �j Y Z � lyC' �, 0// �`f t LJ' Signature: <br /> w�+ <br /> Company Address: , c, ceaa <br /> sAda� <br /> All information submitted most be complete, accurate and le Ible (R) RESOmIAL NAME OF TREATMENT <br /> DATE NAME OF BUSIYESSOR ADDRESS WHERE WORK WAS DONE PUMPED (G) ewEAfEr FACILfTy <br /> PUMPED PROPERTYOWNER PLEASE INCLUDE SYR=_ET r, DIRE "". STREET NAME nN0 CITY pIEWCAL <br /> J <br /> Q <br /> = Cay <br /> : <br /> ti <br /> W <br /> w <br /> W <br /> W <br /> 1 J <br /> �..:% I <br /> 6 <br /> D] <br /> m <br />"1 <br /> m <br /> O <br /> tll <br /> Q <br /> O" <br /> 0 <br /> v <br /> Car �- <br />�'. <br />.. CIM <br /> a <br /> x <br /> n <br />� sEprAct cIPANERs REPON <br /> E'er 42-04 <br /> iJr0.D7 <br />