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O <br /> O <br /> SAN JOAQUIN COUNTY <br /> o j ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12"of each month <br /> O <br /> CV Telephone: (209)468-3420 Fax:(209)464-0138 Web:www-sjgov.org/ehd <br /> co <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: A "\S s- C-' e CRT Report for the month of:� ear 20f <br /> Ln Company Address: 6 S3 S 6 -„ S� �� C,�} �3�0 7SiJ_ <br /> StreetAddre5s city Zip Codi gnature: <br /> O <br /> �- <br /> All In tormat)on submlttad mast be complete, accurate and legible <br /> CD DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS JR) NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACIUTY <br /> t` PLEASE INCLUDE STREET Y DIRECTION STREET NAME AND CITY C CHEIACAL <br /> CV <br /> city <br /> Cltv <br /> e� <br /> city <br /> ity <br /> C <br /> r/ CI <br /> o� <br /> ro <br /> !^ city <br /> !r �•L <br /> � <br /> city <br /> c� <br /> It <br /> Ci C-4 <br /> 1` <br /> a a C <br /> RY 0 <br /> cit <br /> Q <br /> C <br /> cit <br /> U <br /> d- <br /> i <br /> citv <br /> O <br /> QJ C--4 <br /> C.0 CI <br /> tycity <br /> CL V <br /> Cfty <br /> D <br /> CZ- <br /> N CI } <br /> 4- <br /> Page of <br /> Y <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> F= 12/27/13 -— <br /> a <br /> O v <br /> i a <br />::a w9 Iml �i trs <br />