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Qp4t�lM,_� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Ret <br /> this form by the <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> i <br /> Company Address: - Report for the th of: C year Ae)4' <br /> Street Address /I� cry Signature: <br /> Zip Code <br /> All information submitted must be complete. accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED �- GREASE TRAP NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> cit S d-elc 11 <br /> 0� '�/,// v� <br /> y/v LJ B city ' I <br /> QUI✓ L 1/ / �t/ Wlev v p City <br /> CSG' N 4 Cit <br /> .3�JS— Si r��ii Cit <br /> cit <br /> �dl() // p, cit <br /> ll It � l <br /> /1/ cit <br /> Y� (7cS�1fG�C/' <br /> cityl( <br /> Noo vlq-6 1t l <br /> WET le 7 City pcity <br /> t <br /> i <br /> 3l y E Cit F9 ci!xf <br /> Cit // r <br /> YY/� City111A 11 <br /> City <br /> EHD 42-04 <br /> Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />