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LNVIRONMENfAL HEALTH DEPARTMENT Return this form by <br /> w t 600 East Main Street, Stockton,CA 95202-2708 the 12D'of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> • ly �P <br /> `` -.1 SEPTAGE CL ANER'S REPORT <br /> Company Name: L� VYl Repo oath o : yeap __ <br /> Company Address: Signature. <br /> Street Address City Zip Cade <br /> All information submitted must be cDm lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) nesm NTfAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GR 1 P FACILITY <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY C) CRE L <br /> )a 1 I (r CI <br /> city <br /> la a(o ca <br /> 1 <br /> ate/ ✓1 G Q � <br /> ca, <br /> City <br /> IU �' Ci <br /> P City �SAA'62 <br /> Cit <br /> city <br /> city <br /> City <br /> Ci <br /> City <br /> City <br /> City <br /> City <br /> ca <br /> ly <br /> EHD 42-04 squ0cesspooi Repon <br />