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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:WWw.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � " <br /> W0i'nJ4 CS Report for theth of: <br /> ,'z yearSSC° ,p <br /> Company Address: ,&I% Signature: '�i[JL� v <br /> Street Address city Zip Code <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER PUMPED G) GREASET NAME OF TREATMENT <br /> FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> Lam'. cit S7162'41 /S6 S GI:/ <br /> C ityEA <br /> I s�� r I <br /> City <br /> cit aU� r <br /> cit <br /> iv Cit > 5��� , I I ► <br /> 3 D ,T4v-fit - u'82014a 2722 tV PIWN /i1/x--' City z $�� <br /> P0110 L0 City 11Sl d <br /> 27/9 Ci <br /> /yil i/✓ �/D 6' !`Li h/� � Cit 6- <br /> Cit,cit <br /> MCAA, 3L/3l� rUUnj/� 7/1/M/ 46 - Cit �CI�J c <br /> o��N�C. 3(��0 STN- ✓iLir�LrE /�'i1 Cit SUv i/ <br /> _ city <br /> d/LT/4- z/"e l''-w Cit <br /> at <br /> Page of <br /> EHD 42-D4 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />