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a44u f?t.. <br /> n ' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> lot� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ''�}. Telephone:(209)468-3420 Fax:(209 464- Return this form by the <br /> 0138 Web:www.sjgov.org/eh6 .12th of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: % ��� `S2 �✓ <br /> Report for the month of: <br /> Street Address A�� Sd.� yearo7y/" <br /> All information submitted must be com tete accurate acity nd legible <br /> ZiP Code Signature: <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE <br /> PLEASE INC!_UDE STREET # DIRECTION, STREET NAME AND CITY GALLONS *(R) ES NTIAL_ PUMPEDREASETRAp NAME OF TREATMENT <br /> e� CHEMICAL FACILITY <br /> Cit o/CL) <br /> L J l (✓ fiJ SCVN,,r l ? <br /> city <br /> ` OZ GtJ <br /> Noir �z <br /> �1 City. / / <br /> Cit / 0070 ,7 <br /> _•' �° "� -�3 b � � ��� cit <br /> 0�(7 4, Cit <br /> Cit SSD <br /> c•� Aw ,4 �� � -0 <br /> cit <br /> Cit <br /> �a ,1 C` 62c)J u r2 Un. cit I <br /> �'/ _ C i <br /> Ali. .$0 / <br /> cit <br /> / CR" // <br /> Ci <br /> Cit <br /> Jt <br /> EHD 42-04 <br /> 12/27/13 <br /> Page - of <br /> SEPTAGE CLEANERS REPORT <br />