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i&ib SAN J0.4.01TINCOUNTY T <br /> ENVIRONNffiNTAL HEALTH IDEPAPMEENT Return this form by o_ <br /> 304 East Weber Avenue,and Floor,Stock-tori,CA 95242-2708 <br /> the 12`6 of each mtintb o <br /> TWL-phone: (209)466-3420 Frac:(209)464-0138 Web:vtivtv.sjgm.orgfehd m <br /> SEPTAGE CLEANER'S REPORT <br /> Company Dame; Report for th onth of: year SCJOR <br /> Company Address,. Y7501 /^ � Signator p� <br /> Streei Address Ciq Ziff Code T <br /> All inform- tiolt stt6milted must he corn letc accurate, avd ie i61c 1 <br /> DALE NAIE OF BUSINESS OR "DRESS Vi'IMRE WORK WAS D ONE GALLONS W1 UKSTDL`lr kt. � <br /> PUMPED PROPERT'4 OWNER (0) t:l u,. T1UP NAME OF'1'REATNIENT m <br /> PLEASE INCLUDE STREET U. U18ECT1ON. STREET NAHR AND CITY PUMPED FAC.'II.1'1'lr a <br /> (C) ORMUCALCity d79 LA J <br /> tl i 1 Clay \.r: fJ <br /> 62 <br /> City 1.t 104)0 <br /> r7 p <br /> VC <br /> City <br /> Qrt <br /> city <br /> r city kL <br /> Ci ly <br /> cis• <br /> C <br /> City lL !1 l 1 tn <br /> Lt r <br /> City <br /> ` L <br /> City <br /> -01'4 �[ �� l L <br /> city Ale)6 <br /> r�l� Cih• �p�t Q CJ <br /> City 6t J L L �� o <br /> 0 <br /> N <br /> City o <br /> N <br /> Ciry <br /> T <br /> Ciry• <br /> N <br /> C 1tv <br /> EHD 42-04p7Ff./� /S,t <br /> 8/30104 <br />