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0.t4H1*K601'� <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: �� /�(1f Report for th nth of:&n0&1 year�a2� <br /> Company Address: �� ,� Signature: <br /> Street Address City Zip Code <br /> All information submitted must be com tete, accurate, and legible <br /> DATE NAME BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER GREASE NAME OF TREATIMENT <br /> TRAP <br /> PLEASE INCLUDE PUMPED FACILITY STREET #, DIRECTION, STREET NAME AND CITY CHEMICAL <br /> cit ;t �A <br /> Gl►/v i i9atlA L AIA-6 1,1,06 A)4vcit / I �l✓ I <br /> 2 V-3 AL JAI, 6iL XVIW city / <br /> i MII JI I��h1G- ' Z 7 696 so'fU t 1 4,10 Cit <br /> ifiaa� �C Cit 3 <br /> 23 96 vv� <br /> Cit <br /> 7660 Nil 7'--S-6A) `G /C— o Cit <br /> 1? at <br /> o/�o Lo a Ga-,- Cit of l l <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />