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rq�l ' SAN JOAQUIN COUNTY <br /> �ae.Fa-cow <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East I-lazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: A,a i 04 Report ; <br /> for th s✓v / <br /> Company Address: /135? h/ I&�j . 6� '3C� Signature: th of: year�� <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL ZRACILITY <br /> F TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED GREASE TRAP <br /> / PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> 17/54Y/ <br /> Cit d 5 C l �y�v jCit , <br /> y/- /�v// �� /� 8d ,/�So#Uti� t�,9.o City r t <br /> olzw SCE 1 UV W• &W cit <br /> L-7 vs'Gv h� 9 . SP/#&CTS RV40 Cit i 0110 c r I t <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Page S— of 5' <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />