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LD ria o L iu S'AMJOAQUIN COUNTY <br /> LD �... <br /> m EN ENVIRONMEf�rAL HEALTH DEPARTMENT Return this form by the <br /> L HEA171i 1868 East Hazeftorl Avenue, Stockton, CA 95206-6232 <br /> w ra<„ ""ACES Tele J9 ?2t' of each month <br /> Telephone: (209}468-3420 Fax:X203} 464-Q138 Web:www-s ov.or /ehd <br /> <I - <br /> IL <br /> SEPTAGE CLEANEri'S REPORT <br /> Company fame: /� pv��• �`�3 C <br /> R s eportRepot for the rn Eh of v year�� <br /> Company Address: ,?p( �o ta-r ofo �e o Ce,. ��35� <br /> Street Addres Sig nature_ J <br /> City Zip Code <br /> Alf infurmati-n submitted must be CDm tete, accurate, and Ie ible <br /> DATE NAPdE OF BUSINESS OR <br /> PUMPED PROPERTY OVINER ADDRESS WHERE WORK WAS DONE GALLONS !{R} RESIDENTIAL <br /> PLEAS E INCLUDE STREET 4, �IREC7fON, (G) GRFASETRAP NAME=OFTREAT7dENT <br /> PLfN1PED <br /> STREF3 I[AAtE RND CITY C FACILITY <br /> H ' � } CFFEIAfCAL <br /> W cd-JIr ���� , ' yrr Q YCq <br /> Ile <br /> L/.wti4 <br /> LE <br /> v <br /> City <br /> City Trode-.V <br /> �f 449 q LJ�M,► OSS C i ss, city • �0 ,, <br /> o <br /> /'4 c <br /> C14 OJ CffCD <br /> 7� <br /> ST <br /> O,� Cf <br /> � cif o <br /> N <br /> Ci <br /> CT) <br /> cls Cit <br /> Q <br /> Cil <br /> LD <br /> � Cit <br /> m , <br /> CV _ <br />� Page of <br /> CD EHD 42-04 <br /> 12127113 a <br /> m _ <br /> CD SEPTAGE CLEANERS REPORT <br />