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. �4'4tulfi,.� . <br /> q SAN JOAQUIN COUNTY <br /> : ENVIRONMENTAL HEALTH DEPARTMENT <br /> - 1868 East 1-lazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web; 12t" of each month <br /> www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: j'' Ali-�� �� Report for the-Month of: <br /> year, <br /> AStreet Address City zip code Signature: <br /> ll information submitted must be Com tete accurate and legible <br /> DATE NAME OF BUSINESS OR l/ <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY GALLONS (R; SIDENTIAL <br /> 7PUMPED oREASETRAP., NAME OF TREATMENT <br /> 2 <br /> /-7 C CHEMICAL FACILITY <br /> ,m "nom/�/ cit <br /> �C l 7 VU /TW 1? ��, � 1 C << <br /> ���'� Cit <br /> G Tl�/o /97/� . <br /> 4isTaG cit ? <br /> a2 GI/�r �. <br /> cn . <br /> L /-h/ '70 JCity <br /> �on1h` il/cSi� <br /> Cit <br /> C�s� <br /> f l f/ (�1/✓��/✓�JR—p 1 r <br /> a� <br /> • /s�J <br /> TL (//0 T 73 6 <br /> ��ZZC� cit <br /> a City <br /> _ at <br /> U <br /> � <br /> --_City <br /> d nl �S UAa l y�17 Gil. 4r' <br /> AtJ7ptj -v 1)X / Cal Cit <br /> t �N cit <br /> EHD 42-04 <br /> Page Of <br /> '12/27/13/13 <br /> SEPTAGE CLEANERS REPORT <br />