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�qutn SAN JOAQUIN COUNTY <br /> ar . <br /> ..bra Cati <br /> ENVIRONMENTAL HEALTH DEPARTMENT 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: ii)sv2 C� �6�'I �UZ _ Report for the onth of: 9/11 <br /> Company Address: /��$� ��/ �, �G972lD /�, C'qG' Signature. L ``� � <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 AL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #A,�DIRECTION, STREET NAME AND CITY 'y (C) CHEMICAL q <br /> 3 a7 i5 J�W YV77C/�rOtT FJ�(/ E' � f��C'v r� Cit Ae Ul�� � GIJ <br /> -�fi�/I!1 eft �i4D <br /> city <br /> r ,� 1 <br /> o Zg e23 9 Al, 49-yVir-e RV19,0 city �Li0�2��0 � � A � I <br /> Cit <br /> Cit <br /> C it <br /> Cit <br /> Cit <br /> city <br /> C it <br /> Cit <br /> Cit <br /> Cit <br /> city <br /> City <br /> Cit <br /> Cit <br /> Page _of J <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />