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-� rqx I?L GENIE® � E EIVED . <br /> .� <br /> CC SAN JOAQUIN COU14TY <br /> o1u ENVIRONMENTAL HEALTH DEPARTMENT OCT 2016 <br /> 1868 East Hazetton Avenue, Stockton, CA 95205-6232 6NVI . <br /> Return this form by the <br /> w . . -- „ <TAL HEALTH Telepho>le: (209)4&8-3420 Fax:(209) 464-0138 Web:www,stgov.or�Rphl�! 12th of each month <br /> EN'; H <br /> MSERVICES iT/SERry�CES N <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: e <br /> —Z&ep r X2 �" i <br /> / Report for them th of: year <br /> Company Address:_ r�Ol Aeos�o-e I'Q / <br /> StreelAddress c;t� C4. �S3s2 Signature: c <br /> C6." Zip Code <br /> All information submitted must be com lete, accurate and legible <br /> GATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS UVHJ RE WORK WAS DONE GALLONS I R} RES1Q^cN71AL <br /> ReAT <br /> PLEASE iNCLUOF STREET N, DVPUMPED (G)fRECTIDt4, STREET NAE AND CITY Ic°? GRPASETRAP NARiEO ILITY1tVENT <br /> /O 2,,11 CR `O (C) CHEMICAL <br /> 4/� 13 <br /> CR L� �r• 3y� <br /> 113 �q� �lr� �• �S6C0 rra <br /> 4 C74 <br /> °I r�9c.. a.l• city lS L �� <br /> ,tel• ✓"L Cit � ar y yp� Y c7 t/t <br /> OVIC S <br /> Cf! <br /> �G � o: <br /> � o <br /> Cit � <br /> N Ci <br /> V <br /> m <br /> V <br /> c� cif r <br /> In <br /> M <br /> CS) cit o <br /> c� <br /> ! <br /> c <br /> r-I cry - <br /> LO o <br /> r-I <br /> Ci <br /> �o <br /> � cn <br /> CD <br /> C\4 <br /> Page of <br /> —r <br /> EHL)42-114 <br /> m <br /> 12/2713 <br /> .—I SEPTAGE CLEANERS REPORT a� <br /> ■ N%%M <br />