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0.r4u I>+ <br /> ''�c°c SAN JOAQUIN COUNTY <br /> x HEALTH EALTH DEPARTMENT <br /> Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT y/ <br /> Company Name: /YJ v (� SR Report forth moth of: /�s�G <br /> year a <br /> Company Address: 1�-),44h7), � � /��, /� <br /> Street Address City ZipCode Signature: �!4 <br /> All information submitted must be com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDEN IAL <br /> PUMPED PROPERTY OWNER NAME OF TREATMENT <br /> PUMPED G) CHEMICA P FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICA <br /> c �C <br /> it �S- <br /> n�N �G S/rld �/ 5 DIST Ol i%� cit /I Qv <br /> I?3 �� ;�v �d ti ;)� sr �T city <br /> /P) / 05al Cityf <br /> ! / �d�/ <br /> � h iii/ �� /v�/ r/-���r6/ Cn /i SCJ <br /> 7 4-5a-Z110 9W-) Cit <br /> City- <br /> 71 <br /> it <br /> cityI( / <br /> •!'` ,^%'� � � : City X Sit U <br /> 12 llQa G 1�. 02 �� v, l��l�/� Cit /r S7J <br /> 4 71—Z `14 7 C 1 f/ � cit /I <br /> / Cit <br /> J� Osv.9 Cv.S' <br /> cit <br /> i 6- <br /> .2,62 14Vf City / I 3 Ude <br /> /C ✓' �' �ii +/� <br /> City <br /> / BUJ <br /> MwIrl _� (7 /I <br /> Cit / Sad <br /> Page of b <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />