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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: fl � �� /�� �� .�/�� <br /> 4 Report for the o th of: S year -1, 6)/Company Address: �.j���''�� �. ��� -) <br /> Street Addressa Signature: <br /> City 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 TRA NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> CHEMICAL <br /> cit)( <br /> cS' ch <br /> city. <br /> i ry-1W e"02A cit <br /> &01 L4 � <br /> Cit <br /> <t D 9141/ 1 cit <br /> m" r <br /> ,mac, cit <br /> l So�IJ r 3U uAZLAIZ2 �it�L=� '�/� <br /> I� cit 5"223 <br /> G L cit ?/ <br /> cU l� Sfu rTE o cit <br /> city <br /> r /Sod I <br /> r �Uk lail r1Q106-vi Als Cit 1 dJ l <br /> o 14,&7-1172 city <br /> cit i t i r <br /> /C �;/�j city L <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />