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RECEIVED <br /> u.rr :3 <br /> SAN JOAQUIN COUNTY FEB 17 2015 <br /> ENVIRONMENTAL HEALTH DEPARTMENTReturn this form by the <br /> 1868 East Haazelton Avenue, Stockton, CA 95205-6232 12''of each month N <br /> • <br /> Telephone:(209)468-3420 Fax-(209)464-0138 Web:www.sjgov:org/eli+AL HEALTH <br /> v1�Fc <br /> SEPTAGE CLEANER'S REPORT i <br /> Company Name: !� h. S � dile G� Report for the month of: yeah 04f- Cf) <br /> Company Address: L p-„ It� Cf} 1 3-3d7 <br /> �n Stve Ad dress Signature: I < <br /> City Z1p Code <br /> N All Information submitted must be complete, accurate and ie ible <br /> DATE NAME OF BUSINESS OR (R)ADDRESS WHERE WORK WAS DONE GALLONS �snE NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (C) CREASE CHEMICAL FACI ITY <br /> PLEASIE INCLUDE STREET >7 DIRECTION, STREET NAME AND CITY C GRASET <br /> z <br /> 0 <br /> Gity <br /> 00 ! ^ rn <br /> rn <br /> A <br /> city <br /> w <br /> Ci c0 <br /> v <br /> I <br /> C' w <br /> I � <br /> "4— <br /> city <br /> O <br /> cityV <br /> i <br /> city <br /> IV <br /> C RyCD <br /> I <br /> j 0-1 <br /> city <br /> city CD <br /> W <br /> Ci <br /> City <br /> Cit rn <br /> v, <br /> CftyI D <br /> Page of CD <br /> EHD 42-04 CD <br /> 2127113 <br /> SEPTAGE CLEAN ERJ REPORT <br />