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zr ti� SAN JOAQUIN COUNTY <br /> " r ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Ret <br /> this form by the <br /> t;;�� �~p Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: <br /> Report for the th of: year_L <br /> l� � /' _ <br /> Street Address city Zip Code <br /> Signature: <br /> All Information submitted must be complete, accurate and le ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS �R) RESIDENTIAL NAME OF TREATMENT <br /> '77PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED �REASETRAP ' FACILITY <br /> CHEMICAL <br /> � Cit <br /> Cit t UJ 7• / I <br /> �wlgz City <br /> cit <br /> Ito l cs@�fu CT i2v J ( . ? <br /> City / <br /> Jf/�►//�� c�(J (� N /�� /`� cit <br /> ! � l <br /> Cit <br /> D City ell /t <br /> G✓�� Cit <br /> cit <br /> 40_ <br /> cit <br /> .. <br /> City <br /> cit <br /> L �c3 l �J�[ - c��G�C/i� ✓J cit <br /> 3/ 111 ���(J �r d' �C✓� RD i � Uv 71 pa9e__`�of <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />