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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEt T Return this.form by the <br /> 1868 East Hazeltgn Avenue, Stockton, CA 95205-6232 12t1i of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:,,www.sjgov.org/e,,hd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �! " 1 C 1134 - G�yj i�lll Report for the nth of: year;?o/7 <br /> 1.�.z <br /> Company Address: , 76z� I iw 0,61, $ Signature: <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) RESMENTINL NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER (G) OREASETRA' <br /> PLEASE INCLUDE STREET a DIRECTION STREET NAME AND CITY PUMPED C CHEMICAL FACILITY <br /> city <br /> cityv <br /> city. l S�tJ <br /> Il aw_ xz t fi a cit / <br /> cit <br /> J� Ai 9 '1316 e� Cit I .511 <br /> II��Nn �'lr�iR/ /i <br /> city <br /> /�J3 �� city // rJ <br /> city71 <br /> /72 cit 11 1 <br /> l/r u L4 5 city 7 <br /> A) C 33 J, _';7 ci <br /> city <br /> Q�l i' 6'T cit <br /> 0 /ill i -0/T city <br /> / <br /> 2, r l <br /> Page :T Of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />