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SAN JOAQUIN COUNTY Return this form by the <br /> t e <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 95205 6232 12th of each month <br /> 1868 East Hazelton Avenue, StO&tcn, CA <br /> Telephone:(209)468-3420 Fax: (209)464-0 I38 Web:v,Mnr�.s�gov.orgJehd <br /> e�tytiK <br /> SEPTGE CLEANER'S REPORT <br /> r Report for the of:N earn lC <br /> Company Name: 1/Signature: <br /> Company Address: sv��tHa 5 c° <br /> +Ir <br /> o�l� <br /> Alt Information Submitted must be corn lete, accurate, and le ible GALLONS (R) RESIDEPUTAL NAMF OF TREATMENT <br /> ADDRESS V%rHERE WORK WAS DONE PUL7PED (G) GREASE TRAP FACILITY <br /> DATE NAVE OF BUSINESS OR CITY C cREWCAL <br /> PUMPED PROPERTY OWNER PLEASE INCLUDE STREET 9, DIRECTION, STREET FIAFrE AND <br /> 33 G' u <br /> i� 01 <br /> K <br /> 42 <br /> d- <br /> i <br /> II �S <br /> cityt,t J <br /> z <br /> I c� <br /> I � I <br /> LC <br /> City o <br /> Cil <br /> I _ <br /> C Q <br /> 4I <br /> i C& <br /> Page of <br /> :i <br /> I <br /> SEPTAGE CLEANERS REPORT <br /> I <br /> i EHD 42-04 <br /> 12/27/13 <br />