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aG�UtI <br /> SAN JOAQUIN COUNTY <br /> " ' < ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web;www.sjgov.org/ehd �Ztl' of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: vS /fiej �2� L <br /> Report for the nth of: year <br /> Company Address: ��.�.��"'"��� „ L <br /> Street Address Signature: <br /> Clty Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME BUSINESS OR ADDRESS WHERE WO (R) RESIDENTIAL <br /> PUMPED PROPERTY <br /> RTY OWNER RK WAS DONE GALLONS oREASETRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DDI/RECTION, STREET NAME A7N�D C/ITY PUMPED FACILITY <br /> / f/�i /YAG city ,��0 / uA CHEMICAL <br /> City <br /> off/ >U <br /> City > I <br /> avZ , v ISV797 Age/':-7if cit 1 / <br /> _ rA1 /I t 1 <br /> Cit /� <br /> Cit <br /> i l ; /1 <br /> cit t <br /> a 3 /�Gl h1 — G/r/ ✓ cit <br /> Cit > -5iv <br /> /^ <br /> city <br /> cit / I <br /> �7 , r <br /> (� d s - - 1 Cit <br /> a �s sc T T City <br /> / L- Cit <br /> a WeW-1) /1/,'�(�i��2�>� Cit <br /> Page <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />