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SAN JOAQUIN C- UNTY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT Return thisform by the <br /> 1868 East Hazelton Avenue, Stocldon,CA 95205-6232 12tH of'each month <br /> r Telephone:(209)468-3420 Fax:(209)464-0138 Web:;WWw.Sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ll G A"iklzkl S'/�G Gds MIG Report for the nth of:/// 1 year 0/ <br /> Company Address: B 4 ,+ j, /Tl� �¢ Signature: 1 �� <br /> Street Address city Zip Code <br /> All information submitted must-be com lets accurate and legible <br /> DATE NAME�OF BUSINESS OR (R) REsioENnAL NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED 1 aREASETRAP FACILITY <br /> PLEASE ,IN/CLUDE STREET p DIRECTION STREET NAME AND CITY CHEMICAL <br /> o�(7city <br /> city. ( JSaCv 1 r <br /> cit / <br /> cit r �( <br /> Q IA2 e d i ,cit 1 p/ <br /> 'City <br /> Cit <br /> city <br /> T city <br /> � cJ � <br /> c1tv <br /> 10A 0 city oo <br /> ihM1V41,r &L city <br /> City <br /> Page of <br /> EHD 42-04 <br /> 12127/13 SEPTAGE CLEANERS REPORT <br />