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apRultf. <br /> e.e�'foti SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stoci<ton, CA 95205-6232 Return this form by the <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12t" of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Report for the month of: year c' <br /> Company Address: .3s� //`� 4�� Y <br /> Street Address _ ' � Signature: rile <br /> City Zip Code —'�"L <br /> All information submitted must be complete. accurate and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS JR) RESIDENTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY PUMPED GREASE TRAP FACILITY <br /> O cNEMICAL <br /> �� <br /> Ci <br /> L/ r % ��1 7 r �i r I <br /> Ci , <br /> city. <br /> All Le ,o � ci <br /> 57r 7t I <br /> u o27a GAJ 1)'14,!e17�Gy�l/ <br /> cit <br /> ' Pt Cit <br /> l <br /> / L Tse i <br /> Cit r i Sov cJ <br /> � Cit <br /> fYIe�ON��1' � /5 ?�i.�� /�>�"Z �✓�/. <br /> city <br /> 5y� <br /> 7 C Ly cit 1( 1 l <br /> cit .17 <br /> tt171u / 7 �C� u C%�Gl�FJ�� Cit <br /> T w l� /7 UJ <br /> - Cit <br /> Cit <br /> --w 15- v- <br /> �'� cit <br /> Cit <br /> Pag of <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />