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aR4uIM' SAN JOAQUIN COUNTY <br /> obi-•.ati <br /> r ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623212th of each month <br /> • q-- �b".• Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � � ie �- Report for the th of: year <br /> Company Address: J U / ,��- � /p• Signature: <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 NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED GREASETRA FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION. STREET NAME AND CITY ) CHEMICAL <br /> �/f�►� .�� Cit G AVQ44E17011ELr <br /> cit �i <br /> C ty 1 /c <br /> As- '5i*111A111"-" S' X- A V C ity oo <br /> Meb6wfi-(& 113 Tlilt d ,to c ity 16wle . <br /> w 6//D v a4W %'r/ r Y cit '—p <br /> City <br /> 3—,ail I s D3� 1-7-e city z til C'z— <br /> - L/7� c��- Z4AJS cit <br /> City <br /> W-6 —lu `^ 02727 W Cit /7 t i <br /> city <br /> .17wo / Cit �V � / /� <br /> Cit <br /> City <br /> v yYlu f B fI T i,�J% P�nc -c, cit <br /> cit 3�() sn//t)d'z:-- <br /> Page of <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />