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Q�,441?r, <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12ti' of each month <br /> `+c; �•a�:�� Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: . b814 SsRC �`pl/r Report for the month of: year �v <br /> Company Address: �35� <br /> L -�� Signature: <br /> Street Address Clty Zip Code <br /> All information submitted must be com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WASDONE GALLONS �R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER G) GREASE TRAPi NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED C FACILITY <br /> ) CHEMICAL <br /> nl ZI)S'7 =�� -1 City 7A�.4 <br /> Cit <br /> � kl 7�Gt/ City41 <br /> "� 62,f 11317 Cit <br /> city oo <br /> / 6 F/1,4rV Cit S-vd i t <br /> cit 1 $2)tJ <br /> v cit <br /> �'X5cJ�I�LDf at✓S D i �!_ Cit SOcJ ( L l <br /> laVal/� S r14 IR ' %� / <br /> cit <br /> AZ Sici cit i/ t <br /> It <br /> JVe " CI <br /> 2 c z--Ait/G cit <br /> CityMpp -±� <br /> � I <br /> City <br /> C 3 // e cit <br /> Page ofd_ <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />