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• 4g Ih <br /> a: <br /> SAN JOAQUIN COUNTY <br /> a ' < ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 RRof each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd th <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: silD�/!in/� , <br /> Company Address: <br /> Report for the month ofyl�f/ �7 year <br /> Street Address <br /> l�y'��C��F,� �3�,,,L�y,¢�ld ����6",eiJ77i � CiS��n .C � <br /> city Signature: <br /> Zip Code <br /> All information submitted must be complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER oREAserRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> C CHEMICAL <br /> -sloeltaw / o SFiGtJ�� <br /> ,9>& Mktl /I <br /> city11 r c r <br /> 0 � city <br /> Aev(/ <br /> 410 C Ity 0 /( <br /> ci <br /> Ci <br /> U. l) l��zS%�r� i ✓�a�D ci / �j/G1 I l l <br /> S%C�7 IJtiJZWIFE city U f I I <br /> �,n L`s x/70 A/�/L �/,1/i9�C�E� � � ci > l <br /> [Y R-7.7U) /�' ,� ��y� Cit Z/ 601C) I i <br /> 7— city <br /> 9S0 fit/ % i <br /> ci <br /> �S7"c W �S9'l� �%5'G Gtr K0, city <br /> 0-r1GU t' / �G�IfLtGT� /�D cit <br /> cit <br /> City <br /> Page of <br /> EHD 42-D4 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />