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SAN JOAQUIN COUNTV <br /> EmVfmm� •IENTALHEALTHDEPARTNENT Retul-IL this fori11 by <br /> tic[ � ppii TT�j 304 East Weber Avenue,3r3 Fluur,Stockton, CA 95202-2748 the 12`'of each III oil th <br /> FE t� F LL.IL� Telephone:(209)468-3420 Fax:(209)464-0138 II'eb:wmv,sjgov r h , <br /> pE�NI1�,JSERVtiCES SEPTAGE CLE ANE R'S REPORT <br /> Company Laine: Report for tLtiOtlth of: year—�20 /V <br /> d <br /> Company Address: � A 7 �►' � ��� a v Sigltafure <br /> Stice Add[ s City Zip Cedc <br /> All inforrna[iou Submitted must be c mplelco accurate rad legible <br /> DATE TNANtf OF BUSINESS OR ADDRESS WaERE SYORKWAS DONE } RFSIPFNrlAL <br /> GA�lAT�S (G} caeASETtt�tr NAME OF TREATMENTPUh(PED PROCCATYUI�7VER I•LEASE INCLUDE STICEPT 0, DIR[CTrOH, STREET NAME AND CITY PUMPED (G) <br /> Q CHEDI7CAL <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> CSty <br /> City <br /> aty <br /> City <br /> City <br /> Q <br /> ch <br /> O City <br /> City <br /> 0 <br /> i 4ty <br /> t City <br /> O <br /> Ctcy <br /> EfM 42-04 <br /> Sl30/04 <br />