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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �EC�� '2th of each month <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT 0Cj 15 2012 <br /> Company Name: 61 Calm Ino B Q Q--- CLOD ub Report$►►�� onth of: 5S P0-. year Q-Q(- <br /> CompanyAddress: �• O • fix. C1 a3 Sari Mocko ( 4, 944 Signature?' �trt� <br /> Street Address City Zip Code <br /> All information submitted must be complete. accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS IRI RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (0) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET 4, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> qA t- F ca M im B04 dub Icam 1 W SOC& city T rm1 tb R c,wex Park <br /> City <br /> City <br /> cl <br /> city <br /> City <br /> city <br /> city <br /> City <br /> City <br /> City <br /> Cit <br /> Dry <br /> city <br /> c1tv <br /> Cil <br /> Cil <br /> Cil <br /> Cil <br /> EHO 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />