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lama <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED. this form by the <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 12'h of each manta <br /> Telephone:(209)468-3428 Fax:(209)4540938 Web:tvww.sjgov,or 0 7 2014 <br /> SIsPTAGE CLEANER'S REPORT <br /> Corn pany Name: ENVIRONMENTALHEALTi �} <br /> Repol-€"FflW W%f: year o- b <br /> Company Address: 67� �a Signature: <br /> Steet Address city Tip code <br /> All Information subrnftted must be cornTete, accurate, and legible <br /> DATE N 4b§E BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DOME GALLONS (R) RESIOENMAL NAME OF TREATMENT <br /> (G} ��£� <br /> PLtFASE INCLUDE TREET A, DIR@GTIt)N, STREET RAhSE AND CITY PUMPED C FACILITY <br /> CHEMCAL <br /> du <br /> coy <br /> / <br /> c� <br /> city <br /> x" v U C-y-- <br /> -qercn <br /> 1SU <br /> Lt <br /> t,1 Irlotf c <br /> AAA c1tvtl <br /> c- <br /> 0 <br /> ci • `" <br /> 0 <br /> Gilyz <br /> cry d <br /> ci <br /> c • <br /> o <br /> I <br /> City `� <br /> city <br /> LEVO <br /> I <br /> C" <br /> Page of <br /> EF:D 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br /> _ U <br /> ■ ■ ■ ■ ■ <br /> ■ ■ ■ ■ ■ <br />