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QP4!t i±1 c <br /> r' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd 12t1' of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: L12 (�_ �� <br /> Company Address: // 6`QjT „� Report forth nth of: year StreetAddressSignature: <br /> City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER PLEASE ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> NCLUDE <br /> GREASETRA NAME FA TREATMENT <br /> ISTREET #, DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> C CHEMICAL <br /> -a -is- 1521 fd//u 4) so T <br /> cit <br /> Nmllleli- V,3 Cit <br /> City. <br /> 28a� svtt ,u� ,6.,. City <br /> i/yy/ ,r/ Cit <br /> 9 S A'�A3/ 12/// N City- <br /> ?w 7 <br /> it w7 ec)w1lt� sou �iz <br /> Cit <br /> L �DO Glx �n��` u/ dTi)z cit �� �.51�v <br /> �l OfJ3/ /L I <br /> Cit <br /> vA� CSXpit >l - i <br /> at <br /> cit <br /> Cit <br /> city <br /> City <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />