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SAN JQAQUI)J COUNTY <br /> C!D Return this form by the <br /> ENVIRONMENTAL f-JEAL-TH DEPARTMENT <br /> 600 East Main Street, Stockton. CA 952D2-3029 12 of each rnorth <br /> a <br /> Telephone:(209) 46LZ-3420 Fax: (209)464-0138 Web:www-sjqov.orgfehd <br /> SEPTAGE CLEANER'S REPORT <br /> yea <br /> Company Name: /m <br /> Signature. <br /> Company Addressi. CA cx�11 e�? Z/1 LP I OoNt <br /> Suee Addpwm city zip Code <br /> All inforwallon submitted most be complete. ar-6uratv, and legible <br /> DATE NAME GFEWSINESSOR ADDRESS WHERE VkFORX WAS DOME GALLONS NAME(W TREATMENT <br /> P LJlW ED PROPERTY OWNER UALWE AND CITY n"ED FAGlLrTY <br /> PLEASE INCLUDE STREET 11, DIRECTLOW, STREET I KPI CINE-c- <br /> Ljj <br /> T�)C. --tI \ 0 <br /> PY 3613 032 !S�r c�, S- C. KJly 60 tA-4, 3- <br /> 1 P - ip, <br /> -7joliJ DY w, w-,4 1)1140 Ni MA fioAf\J c1t, <br /> -�2-0 <br /> ow W'�q cay <br /> 0 —Mexi- <br /> 7- 1 n <br /> [�,i 0L PJA- q 5 45- lacl) <br /> LLJ <br /> CAW <br /> C*f <br /> oty <br /> C4 <br /> 7) IV t L) <br /> rr <br /> City <br /> ENVIRON <br /> PERMIT/ERMM N' <br /> ERWCF�-S <br /> Cky <br /> C&I <br /> Ckv <br /> L <br /> EJ10 42-D4 sEpTAGt=CLEJNERS REPORT <br />