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�Q►,4Hl+�,.F <br /> SAN JOAQUIN COUNTY <br /> •'•. _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> 12th of each month <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> Company Name: <br /> SEPTAGE CLEANER'S REPORT <br /> ���� � <br /> Company Address: Report for the <br /> th of: year--� <br /> /( <br /> Street Address ��� G ,, <br /> All information submitted must <br /> DATE NAME OF BUSINESS OR be Complete, accurate and le ib Signature: / f 11� <br /> Zip Code <br /> I e <br /> PUMPED PROPERTY OWNER <br /> ADDRESS WHERE WORK WAS DONE <br /> PLEASE INCLUDE STREET #, DIRECTION STREET NAME AND CITY GALLONS �R� RESIDENTIAL <br /> PUMPED ASE TM NAME OF TREATMENT <br /> '<— , <br /> L/.� !��, CHEMICAL FACILITY <br /> C /G' tJi4/� Cit <br /> City <br /> Cit <br /> Cit <br /> pit <br /> pit <br /> Cit <br /> Ci <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> EHD 42-04 <br /> 12i27/13 page of<— <br /> SEPTAGE CLEANERS REPORT <br />