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Qnqulry <br /> Cco <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East I-Iazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Weh°www.sjgov.org/ehd 12t" of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �`��/�I l��/D/i�.�J� <br /> Company Address,�� j�G/ - Report for onthof:a year -�r7/-p- <br /> , . ���4 � J <br /> Street Address city Signature: <br /> Zip Code <br /> All information submitted must be Complete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> A _ PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY <br /> CHEMICAL PUMPED GREASETRA NAME OF TREATMENT <br /> FACILITY <br /> Ci / <br /> Cit l <br /> city <br /> pit > r <br /> S /L J <br /> /J�� /�✓�/� �, o?JJO� /� �%} cit t ( <br /> City 1 <br /> T /Y / it lQiv� Cit A l /C <br /> Cit ' Iwo t l C <br /> Cit <br /> G7 CI f 5'�D l c r l <br /> � �110 �� � �' � l� <br /> rj Cit I ( U (t ! I <br /> city <br /> Cit <br /> Cit t fir, t• / <br /> ��' at/-LLci n 27� Gug <br /> Cit <br /> Cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />