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Q►,4ulho <br /> z: SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> �r; � ��P Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ��m��% ,�,,�/ 41-1 Report for the onthof <br /> Company yearo�v/,� <br /> p Y Address: <br /> Street Address Signature:Zip Code <br /> All information submitted must be com tete, accurate, and legible <br /> DATE NAME BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED GREASE TRA FACILITY <br /> �/� CHEMICAL <br /> cit <br /> �s� /77 r� N7vY.� C ity ✓!J� <br /> �r _ i rQ SGS <br /> Cit <br /> Q <br /> I a 3 74%V%T , bL� Cit <br /> �L Porl G4e 2 vs ' •T AOA404z City <br /> Cit /SOC <br /> aUG 2v� 75W ZW&I cit o2 UJ <br /> k*'/F— <br /> Cit , 5�j U <br /> /0 b /L&01' jAli es04/ Cit d <br /> city <br /> /3a() c M <br /> Cit <br /> F /+'wr SO 4 L,� , �� �57� <br /> City <br /> Oy D' Q ��1/5�� / //` cit l <br /> �l City <br /> Cit av <br /> 2-7 7 CJ. fYJ�r pit 1 <br /> Page of <br /> EHD 42-04 4 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />