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1-i RECEIVED <br /> m q�4x I n,.�• <br /> SAN JOAQUIN COUNTY <br /> m _ SEP ENVIRONMENTAL HEALTH DEPARTMENT <br /> Return this form by the(D 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ALF elephone: (209) 468-3420 Fax: (209)464-0138 Web:vv m sjgov.orgJehd 12 o.f each month <br /> PEPWAWSERA .9" <br /> + <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � p,.�q JfYS e <br /> � Report for them th of: <br /> Company Address: ;20.1 �IC DSCae �d year,�Z <br /> 51reelAddress City Signature: �� <br /> L , <br /> All irIfarmaYfon submitted must be corn lete, accurate, and le ibfe Tip Cale <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WA5 DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET k, DIRECTION, STREET NA11E AND CITY (G) GREASE TRAP NaMEOFTREATMENT <br /> Z PUMPED FACILITY <br /> _ 14v {C} CHEMICAL <br /> �3 b <br /> W J Ci r4 <br /> ire vc Cc <br /> p / C�r9 �, • fi <br /> A City <br /> CKJ <br /> �61c/.c 51.,_t/c.X_j <br /> TG <br /> Cil oc <br /> vc 46 CiIx l> S► �� <br /> �f• 9 12 <br /> �� 7 14t •! Ci ✓4« '' <br /> ~��• QrL�4 �44G�ded*C` <br /> vy Gam„ U/Y cit $ r z <br /> N cit 'J <br /> m GG� Q'7 �w dIG S Cil �` �� • / C-4 <br /> ��Cv �•� �• �' S <br /> Cqyspa <br /> �'K• •i Cr $ Cit o� <br /> �..� t <br /> m Ci <br /> Q <br /> City cl-D <br /> m �— <br /> C14 CR <br /> CO <br /> M EHD 42-04 - <br /> m 1212711 v_ <br /> SEPTAGE CLEANERS REPORT <br />. . . . : <br />