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r SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �1��� � 7�i' �/� C�. � ��f��� I,O/�1/Li'. <br /> Company Address: /��� E' � AeZ —�-- Report for the th of• yearo2�'/S_ <br /> ` ' "� � � �' Signature: <br /> Street Address "'y 'Z—'- <br /> Zip Code <br /> All information submitted must be com lete. accurate, and le ible <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 TRAP NAME OF TREATMENT <br /> CHEMICAL FACILITY <br /> City <br /> City. <br /> Cit <br /> Cit <br /> �i <br /> Cit <br /> Cit <br /> C. <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Clty <br /> Cit <br /> Page of- <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />