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CDC. SAN JOAQWN COUNTY - <br /> EWIRO�JMENrAL HEALTH DEPART1.At Ni Return this form by me <br /> 600 East Main Street, Stockton, CA 95202-3029 9Zt° of each rnonih <br /> Telephone:(209) 46LL3420 Fax:(209)464-0135 Web:www-sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: I I V �i I Ti �Vrl <br /> P Y �jt �_ Report for lt�e >}th of: ;year <br /> Company Address_lRo 1 1 U� D �f����� • �l �c���t Signature: <br /> Soret Ad6m2s city Zip Cade G,'- <br /> All ie}orrwatton submitted msct be corn tele, accnrats and le Ible <br /> DATE NAME OF BUSINESS oR ADDRESS WHERE WORK WAS DOME GALLONS (R) NAME OF TREATMENT <br /> FUMWED PROPERTY OWNER—�LIJ ►LEASE INCLUDE STREET I, UIR ECTIO N, STREET NAPE wN0 CITY PtJ711P1=D ryc�r-a, FACILITY <br /> Q <br /> 1 � 3 ,�. �-� � STZGK r\l _:_3G?0 ) ale <br /> 77 <br /> 5i-7 <br /> 0 i <br /> `I I •� c-,-), -E-- ,� �0A , T ��4� )o Wit, <br /> LIJ (10 <br /> vj I ck( Vowwc"' e,-- S DOby <br /> cky <br /> CAY <br /> M <br /> S7 <br /> city L <br /> Q <br /> T <br /> D <br /> c- T4f�TiSFR y <br /> C4 . <br /> D <br /> City <br /> 9 <br /> v <br /> r I <br /> ~ E10 42-04 _ - <br /> lOt4Jp> <br /> SEPI-AGE CLEkNERS REPORT <br />