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Q►,aulty,_� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12tt' 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: 76 &Jy/l1� Report for the nth of: /(/L yearaL'/ <br /> Company Address: <br /> Street Address Signature: <br /> CIt1' 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 cREasE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED C CHEMICAL FACILITY <br /> y <br /> r/JI�rJ oG� ,Gn 9A/ cit NSC/^G/� �4Z �`/T z��:S�dc�'GZ <br /> Cit L <br /> city <br /> fl�Ya > r�/�i�,r/ v ,sem � / d✓;r� P �i� Cit a t <br /> Cit ; )L C <br /> )�9 / L ✓,�- Cit V rJ.E r <br /> ak a /V�U 1'V//v 11441 Cit C / <br /> �4 7 C/y <br /> cit Ft /( <br /> Cit <br /> Gi t t <br /> iLR(] cit— Cit <br /> jG /a 679 Cit 1J I L <br /> City 6w <br /> Cit <br /> City <br /> Cit <br /> sm- s cit - l <br /> s� <br /> r'il1o <br /> t c <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />