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HECEIVE <br /> NOV 0 9 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALT Return this form by the <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/PIT/SERVICES 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: y� b 6�1 <br /> i Report for th nth of: <br /> Company Address: jam` L year a �, <br /> Street Addres / City Signature: <br /> Zip Code <br /> All information submitted must be coma tete accurate and le 1 b I <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY PUMPED GREASE P NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> 1r <br /> av-it/- i B ga 2tI `r s/S�� <br /> City <br /> Ci i t i I <br /> /99y7 <br /> Cit <br /> /a s <br /> 0341 city!/+/ /NLS, �I� � 7®✓G Citz i /r 1 , <br /> A✓C Cit �% II <br /> c �c t !lo /3 d S�uifi <br /> city <br /> I ; I rr <br /> jj City <br /> Ci it <br /> /sv , � <br /> � t9�4-J cit <br /> a.�� �✓. eN���i �� Cit > � <br /> S �2 lP3v <br /> Cit sa) <br /> Loo/Si /iu Cil /tel/1/a/l SG/hvt/C C /l cit / <br /> 26 1✓✓GY4&V <br /> /73C r- utr.)7. <br /> Page_�_of <br /> EHD 42-D4 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />