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gtQaln. . <br /> �.:; SAN JOAQUIN COUNTY <br /> w - EM11RONMENTAL HEALTH DEPARTA4ENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12o' of each month <br /> K f Telephone:(209)468-3420 Fax:(209)464.0138 Weh:wwvr.Sjgov.org/ehd <br /> SEAGE CLEANER'S REPORT <br /> Company Marne: Report for the onth of: Mau,, year <br /> Company Address: S .53 Signature: <br /> crZet Addp6rs vCityZip Code <br /> All information submitted must be complete, accurate, and legible p <br /> DATE NAME OF UUMRESS OR ADDRESS W IERE WORK WAS DONE GALLONS (R) RMDEtMAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GRt:ASETRAP FACILITY <br /> PLEASE INCLUE)E STREET A. IRECTION, STREET HAILE AND CITY (C) CHEHBCAL <br /> �R� �1 J 1 1� <br /> 01 I' L �( `V� (�y1� Ci C-Q Se J L.4j .�{� L( J l 06 <br /> l & cit; Gt i �(r <br /> CityQ o - <br /> r , Gil <br /> lc V 166 V LFj cityK ��o <br /> Ghy <br /> Ci <br /> Cit <br /> m <br /> C—) <br /> Cit <br /> 00 <br /> C � <br /> City o <br /> cr <br /> I <br /> C-� cri <br /> City <br /> C- I <br /> Gly <br /> r— <br /> Page of <br /> EHD 42-04 SEPTAGE CLEAVERS REPORT <br /> 12127!13 <br />