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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 12th of each month <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> , <br /> Company Name: 0 wq a) Ci C 1 u A-) Report for the month of: year x / <br /> Company Address: % • P, l 923 S0s) t4GkC C�! �(�qC; signature: 11PIO-jUa L � <br /> Street Address City Zip Code <br /> A,l,li iimformation submitted must be complete, accurate, and le ible <br /> ATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENIAL NT <br /> P,11MPED PROPERTY OWNER PUMPED (G) GREASE TRA I <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> f Cit JAN 2 0 2015 <br /> city 649H <br /> City FERMIT(SERVICES <br /> City <br /> t <br /> City <br /> at <br /> � I <br /> City <br /> 1 Cit <br /> Cit <br /> Cit <br /> Cit <br /> CII <br /> Cit <br /> cit <br /> CIL <br /> Cit <br /> Cit <br /> 'I <br /> � cit <br /> I' <br /> (crib <br /> -1711D 42 <br /> 1014/0714/07-04 �J ` �� (I t �l l� _ SEPTAGE CLEANERS REPORT <br /> i � �^ <br />