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Q,qul�, <br /> SAN JOAQUIN COUNTY <br /> " ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> "'<«aa `R• Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd i2tn of each month <br /> Company Name: <br /> SEPTAGE CLEANER'S REPORT <br /> v �� <br /> Company Address: /�� J �����+ Report for the nth 4LeZZ961 year D/I <br /> r � _ <br /> Street Address city Zip Code <br /> Signature: ` I <br /> All information submitted must be Com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R RESIAL <br /> OF <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED G) GREASETRW NAME FA TREATMENT <br /> /C (C) CHEMICAL FACILITY <br /> �i1J �G'f�000%� <br /> cit <br /> 3801 10111V T ,BL. ;r <br /> �i W /4� Cit SZL i, <br /> y��j �+ City 52 j > . <br /> D� � i c���GGf%�' �� Cit <br /> Cit 7� gaill <br /> ' L l/ <br /> �) Cit <br /> �'n n <br /> City <br /> L <br /> Cit <br /> s <br /> �GlL.S a3� <br /> Cit <br /> =14 <br /> city. <br /> �Si�i�✓ s �� Rr1r� <br /> Cit c / <br /> 222 Cit11 <br /> GtJ -� <br /> . ?c� <br /> / � i^ o, cit <br /> it l � <br /> cit <br /> City <br /> Cit <br /> Cit <br /> EHD 42-04 Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />