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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.sjgov.org/ehd 2 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: a��i�2i9n'/ i9=11& <br /> Report forCompany Address: 3� '''Street Address Signature• <br /> pCode <br /> All information submitted must be com tete accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE (R) RESIDENTIAL <br /> GALLONS NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY PUMPED ) GREASE TRAP FACILITY <br /> � /�� C CHEMICAL <br /> �7V (! Ci <br /> ty <br /> cit <br /> CIDJ°rFdc7�CuJ city. <br /> v Ci <br /> �a JDI/, Cit / <br /> Al- dui,8 <br /> Cqx <br /> AM0a/r9C0" rL Cit <br /> 4 l �� city <br /> ,d I � r / <br /> cit <br /> Cit i <br /> f'l 1/0 to sio i� s� <br /> City <br /> Cit <br /> cityI CIU C l <br /> Lvo Cit 7 I Sl1d I i <br /> Cit <br /> 3S� <br /> Cit <br /> EHD 42-04 Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />