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• - �4►441li. C <br /> vFa•.G <br /> a SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East I-lazelton AvenueStockton, CA 95205-6232 Return this form by the <br /> +';;�:��, Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: SiQG' ��} ^��" � /•1, ���, �7 <br /> tJ h'1 C�rReport forth nth of: �G <br /> Company Address:/�3� j�f-G/� �L., <br /> Street Address Signature: <br /> City Zip Code <br /> All information submitted must be com lete accurate, and lea! le <br /> DATE NAME BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS <br /> PUMPED PROPERTY OWNER (R) RESIDENTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED GREASETRA FACILITY <br /> _ C CHEMICAL <br /> /7i /!5 Cit �/ Od ( l <br /> r <br /> �— city <br /> Cit i r <br /> T�Ric- /5v cit i <br /> .1� City <br /> /n ^ cit Ly <br /> ,I <br /> , r li <br /> 05_r1% <br /> city <br /> �vvu��,/ Cit <br /> �0�17 � �iJvv� city <br /> City <br /> / �ii''rll,�vv '�.� .�/ r�113f�io✓�� <br /> City <br /> l/ <br /> 1j ci // 3Ald <br /> ti 9 <br /> � ✓ Cit <br /> Cit <br /> izq6 Cit <br /> 616 Cit / <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />