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pqutty SAN aJOAQUIN COUNTY <br /> ;°�e,Rra'-pati <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12tt' of each month <br /> •n........... ;� Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> p SEPTAGE CLEANER'S REPORT <br /> Company Name: �/\ �U,/j'YJ //vReport for the th of:� year <br /> Company Address: j;?�& 0 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 (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> moi✓ /.�7� 15A�r/G` <br /> cit <br /> Cit <br /> B1// �/����lllt/�1�2C�o ✓� City <br /> f e 17/ Fw1V Ile Cit <br /> cit 1 J t r <br /> guiv Ffit � !vb? Cit <br /> yyl DN�CQl �/ /yli �'If � Cit <br /> )W eDC)4(1 '9-' city / I / de,4-04 <br /> l (.D&VAt;-1911 Gtl�Si T� /,�/'�9-c cit J / Sa S�Q tLie/e-� <br /> City <br /> •3�U (/V• 4i5��/f/,� cit <br /> City ad <br /> /I��/ J/VJ�VI r"�/II�Cl14�Z cit <br /> cit <br /> �7^� city <br /> �2v a /o� r 1 lwwz Cit <br /> cit <br /> Page <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />