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'441 ' SAN JOAQUIN COUNTY <br /> r_ ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623212tH 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: �� �0� l�J- Report for the onth of: <br /> Company Address: ���� t�r/�- ��, ` ��� � ��d Signature: "- 6A6 <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 GREASETRAJ <br /> PUMPED FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> �j/-/ /`� off/2Z� d�(Oo�I ��l �/�►J� Cit .� /�/U �� �j s <br /> Cit <br /> �dN J /()a city <br /> Cit <br /> Cit / S W C <br /> City Cn e"IC i�/✓ <br /> Cit ,( .5� ) U(� <br /> A90Q/Ji/� '7!// �7/v Cit �U l �� <br /> 2, Cv &-76 AA417/ kVI-LS DA I Cit / <br /> Coo <br /> - 771 � Z,9.-JF- Cit fir ) s�walc <br /> / !ui// Cit �� 0, d It <br /> Cit <br /> 3o /w(:?w(:? N 1 10o6d12 <br /> 3wl -A Cit �J�1��J L/ ��/� � <br /> D� <br /> A)AW—se 1' il:Alw city l C� <br /> oz: o/ew Cit <br /> �1/[//ZL G�/�D.'O Cit <br /> Page of_�z <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />