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Q,,quttr. � <br /> SAN JOAQUIN COUNTY <br /> "`. ' '•j ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> +t; 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> ��P Telephone:(209)468-3420 Fax:(209)464-0138 Web:WWw.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: / '/t/�>?'1 �/� �� �)� j CrJ- Report for the month of: year a 6)1,5 <br /> Company Address: <br /> Signature: LJi 2 <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R RESIDENTIAL <br /> PUMPED PROPERTY OWNER G GREASE TRAP' NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED C) CHEMICAL FACILITY <br /> & 17 7— cit nS <br /> ltilsi /ZL//��%2//r'' Cit <br /> M/47 ��/�Z �� �cYJ �i��l?�/�lGtl��1 lu City l/ �U , I t <br /> f UE, L`0 ZIAIZ514 - %l L/t Cit <br /> °P(,, 4,9/-) Cit <br /> cit <br /> ct <br /> cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Page — ofd= <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />