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Company Name:
<br />Company Address: *4- -leg* ,14-17 ,c2 CC/
<br />Sirc.4 Aii4m-su --City Zip Co..de
<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />
<br />Return this form by
<br />304 East Weber Avenue, VI Floor, Stockton, CA 95202-270B
<br />the 12th of each month
<br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Bleb: www.sjgo‘%orgielsd
<br />Atjitgd7.3 ce."2.42_,tie_
<br />SEPTAGE CLEANER'S REPORT
<br />Report for th.„.e.z. nth of: year
<br />Signature: ' 624 '"'AY '
<br />it Agfa e s'71— key
<br />Ali informstion submitted must be cam lett, !accurate, mad It ible tNVIKUNMtNIAL CtTiqbqUidd UI/22/ZUU( DATE
<br />ROMPED
<br />NAME OR BUSINESS OR -
<br />PROPERTY OWNER
<br />ADDRESS WHERE-1,143RK WAS DONE
<br />PLEASE INCLUDE STREET 11 , DIRECTION, FTREET NAME AND (*ITV
<br />GALLONS
<br />ROWED
<br />(RI RESIDENTIAL
<br />(G) GREASEULAP
<br />(C) C312MICAL
<br />NAME OF TREATMENT
<br />RACILITY
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<br />EHD 42-04
<br />8/30104
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