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QnR�lrt,_� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:WWW.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for th nth of: G�—VGBAftearvt U/ <br /> Company Address: Signature: y <br /> Street Address Clty 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 GREASE NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> C CHEMICAL <br /> a, City fz�na/ <br /> ,9TH <br /> cit <br /> / <br /> / llo DGrc' 16-10 S UL 1 l <br /> e�v� ,Ds // QST phi lrtl Cit <br /> cit <br /> Y)bllb Cit <br /> vv Cit r <br /> 7S A447WW( /�,1,– ' pit lq��u <br /> " ��� Cit <br /> �v Cit <br /> Cit /i - 7v •S',���� <br /> D �/ Gt�i�'�rcLvo Citz / t 573 L) 1 <br /> Cit <br /> £ORo�ar o� i�is r= Cit Oc' i I <br /> city I <br /> �/- 40 z /W vl ,C Cit �) <br /> 335 cit ( /60 J i t <br /> Page <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />