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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> ti 1868 East Hazeitcp Avenue, Stockton,CA 95205-6232 12tH of'each month <br /> r Telephone:(209)'468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: i C S'/�C etow i�11G Report for t m nth of: T- 1year �-- - <br /> Company Address: 11&30 4(- '4A�. 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 oENTIAL NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER Q QR SE TRAP <br /> PLEASE INCLUDE ST.REET # DIRECTION STREET NAME AND CITY PUMPED C CHEMICAL FACILITY <br /> city <br /> L° l}C�iriC �i�E cit 1 1 <br /> S L4' zlnii t cit <br /> -Al-da ,f t t ti a 7---� s1 �G cit / ( ' <br /> i u v 3 W071, city I l <br /> i'JVo_ 6/ cit //:' ✓� <br /> city <br /> ' )kdj--Xwz,1�A106LDL cityi SIS <br /> 26 70 CR ! Ii 3UJ <br /> citydUJ ' l <br /> city I l /.:?L)O <br /> %',t'v /tJ <br /> city �� 1j7111 l <br /> S%22GL % 6.2 / ✓� cit 1 <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />