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RECEIVF <br /> uta. <br /> SAN.JOAQUIN COUNTY JAN 0 5 2015 <br /> ENVIRONMENTAL HEALTH DEPARTIJIENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 ENVIRONMENTAL HEAL 42't' of each month <br /> Telephone: (209) 468-3420 Fax; (209)464-0938 Web:unwr.sjgov.orgPj8ttq"iTISERVICES <br /> S PTAGE CLEANER'S REPORT <br /> Company Name: �� 't Report forth ' o hof: aro 1 <br /> Company Address: Signatu <br /> Sbe:etAddres- fly Zip Code <br /> All Information submitted mast be complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RFSMEtMAL NAME OF TREATMENT <br /> PUMPEC PROPERTY OWNER PUMPED (G) GFamrmp FACILITY <br /> PLEASE INCLUDE STREE7 P, DI CTION, STREET NAME AND <br /> AAD CITY (C) CHELTDAL <br /> x1b 3 T 196b <br /> - Cd-y - d Cr- E'r1 <br /> - a 7 a 1,A Cry -20,), <br /> a <br /> cn <br /> r1' 7S Y s cityl l �� l 1A <br /> vv City k f 1 <br /> ,4 d dl'4 �- .� u <br /> 6 citG +s l I o <br /> In t N <br /> r <br /> Z4 L4 <br /> c Cit' t� <br /> Page of— <br /> j <br /> EHD 42-44 SEPTAGE C!EAI4ERS REPORT <br /> 12/27/13 a <br />■ ■ ■ ■ ■ <br /> ■ ■ ■ ■ ■ <br />