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SAN JOAQUIN COUNTY <br /> a 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: AO&Illjel UM1 114e Report for th th of:(f�66/ year :�t'i i <br /> Company Address: ,/3 7j�1je)� ego 654 S Signature: <br /> Street Address City Zip Code i <br /> All Information submltt'ed must-be complete, accurate and le Ible <br /> DATE NAME OF BUSINESS ORADDRESS WHERE WORK WAS DONE GALLONS AL NAME OF TREATMENT. <br /> s�rnaP-; <br /> PUMPED PROPERTY OWNER PUMPED FACILITY <br /> PLEASE INCLUDE ST.REET # DIRECTION STREET NAME AND CITY CHEMICAL <br /> "7 &,i sty Ue, `/� �'�1 �i �. city <br /> city <br /> i 6 S N i tyllk / city. X <br /> Sr l(J6 ,s 7�8� ICU- Ec l-k fl /z� city d <br /> cit <br /> citySZ� <br /> o/% Licit <br /> I G �� r7 nS� his CN � C <br /> _ cit t <br /> Ci , <br /> city <br /> city <br /> Cil <br /> Ctt ' <br /> City- <br /> Page of E` <br /> EHO 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />