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SAN JO <br /> :`•.'_..,,r-.:•<;,, ��,� � AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> l ' <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> ASR 5 2013 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> LHpl�ta SEPTAGE CLEANER'S REPORT <br /> Company Narp�`G�`r.CN� �(�I r7� > c� ',� Report for the month of: year <br /> Company Address: . f C� � ,3� C��11 4\-t�tC t q L� L4G � Signature: ))�6LILj <br /> Street Address City Zip Code <br /> All information submitted must be com tete accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Cit TM1fl 4`> 6� "7 <br /> f ) � 1 C:�C�:�1' (--chs< I .V1 Y"t� <br /> , Ca r <br /> 0 ' h'?I , cit I (f-rd'! Inc `' 7 5 <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cil <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />