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Fqk%k try <br /> SAN aJOAQUIN COUNTY _ <br /> L ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East HReturn this form by the <br /> Hazelton Avenue, Stockton, CA 95205-6232 Return <br /> 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: /1/ � ��' i �; �� (�^ l') �rCl✓1��i _ Report for the rnon�h of: J�t year �P, <br /> Company Address: iS Signature: . <br /> Street Address <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) R IAL <br /> PUMPED PROPERTY OWNER GREASE T NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED C CHEMICAL FACILITY <br /> i1 <br /> f�1�f9i2 <br /> y v(1is <br /> f 7- City <br /> � 6) <br /> /1);le�6 <br /> '4& Cit <br /> 0O ' 5,/ ' Ao City <br /> cit <br /> cit <br /> Ci <br /> cit <br /> Cit <br /> Cit <br /> Citv <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />