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SAN JOAQUIN COUNTY <br /> at ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> i=. 1868East Hazeltqn Avenue, Stockton,CA 95205-6232 12th of"each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web wwW.Sj90v.org1ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the month of: elTrn 6w Ve r a c <br /> Company Address: - <br /> Signature: <br /> Street Address ✓�% <br /> City Zip Code <br /> All Information submltfed must-be Com seta accurate and legible <br /> DATE NAME•OF BUSINF' OR ADDRESS WHERE WORK WAS DONE GALLOI13 j!E4P-8'FzTRAP, <br /> NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPEDFACILITY <br /> PLEASE INCLUDE STREET A DIRECTION STREET NAME AND CITY <br /> ?�' �S% r c, C�lz i v <br /> S4,V7 • Gf/ L city <br /> 4i1 139;2C/ t . MW14L city. <br /> V(Jv 0// Cit <br /> 4u e q,1 f o& 7 z" pal", 'o CItj �M SlJt) <br /> cityJ <br /> I=on- cit SLv <br /> city <br /> cit <br /> U/► s s�t. 89 l v �1�u�f /Z�9� <br /> city <br /> L/ JU <br /> —M_,c)No �y33 , <br /> q1evm, <br /> i a J1/ 7 Cit <br /> �692� <br /> cr 5 <br /> r Page�_of <br /> EHb 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />