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}aFR pbti SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> _ 9868 East Hazelton Avenue, Stockton, CA 95205-6232 12"' of each month <br /> Telephone:(209)468-3420 Fax:(209)464-013B Web:vmv.sjgov.or-g/ehd <br /> SEPTAGE CLEANE=R'S REPORT <br /> Company Name: Q S ��G3kj^C-)L-W LDIqCReport for the oath f: year <br /> Company Address: s3Iro Signature: <br /> SbFet A-As City tZip Code <br /> All information submitted mast be Complete, accurate and legible <br /> DATE HANE OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDEMIAL NAME OF TREXTIM=NT <br /> PUMPED PROPERTY OWN ER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET 4, DIRECTIOK, STREET RAN.E AND CITY CREWC" <br /> bcm <br /> OLA, <br /> SOY city i1 tLi <br /> 702. C ( a Ll <br /> �r <br /> City <br /> caym <br /> d- <br /> cit o <br /> C- <br /> Clt - <br /> cityi <br /> citGRYo <br /> I <br /> Cfty <br /> 0 <br /> CI - t <br /> Page of <br /> EHD 52-04 SEPTAGE CLEANERS REPORT <br /> t 212717 3 <br /> M%%% ■• <br />