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SAN JOAQUIN COUNTY <br /> at ENVIRONMENTAL HEALTH DEPARTMEt T Return thls.form by the <br /> 'i 1868 East Hazelton Avenue, Stockton,CA 95205-6232 12th of'each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web-:..www.Sj90v.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � / C S'�C G4�YI ' <br /> Report forte onth of: <br /> Company Address: 3. r�iE �/' �� ,.p./j,Q,z-���,/ ��— signature: l lI° <br /> StrertAddrsss city Zip Code — <br /> AII information submltt'ed must--b• Complete, accurate and le able <br /> DATE NAME�OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS <br /> PUMPED PROPERTYOWNER PUMPED IRI ��o�nA� NAME OF TREATMENT. <br /> °QBE <br /> PLEASE INCLUDE STREET A DIRECTION STREET NAME AND CITY CHMOCAL FACILITY <br /> iJ oGd Yrl i D ci Sv <br /> (/J cit r <br /> '67 Uol g J cit <br /> -Cityv� <br /> o S. M✓%eit Sr <br /> city <br /> cit <br /> _ Ci <br /> tv <br /> Aw co 11 LIP5 1IZU/ Mil- ZIJWZ- <br /> city 1\1 <br /> '/ DAIT 13r9�1/ / cn i <br /> 4 <br /> S 6J iOk 3 'sem Tex/1 ei � L <br /> • Ci <br /> .dais Pte;rye <br /> 1I P cit <br /> > s UJ <br /> dG 1/ <br /> Oi <br /> Page of f <br /> EHO 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />