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SAN JOAQUIN COUNTY <br /> bt ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> 1868 East Hazeltcgn Avenue,Stockton,CA 95205-6232 12th of'each month <br /> r Telephone:(209)468-3420 Fax:(209)464-0138 Web:;www.Sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the o th of:O�l��i/L <br /> year �'i <br /> Company Address: �tclty <br /> Signature: � ?Stmet Address Zlp Code <br /> All information submitted must-be complete, accurate and legible <br /> DATE NAME�OF BUSINE38 OR ADDRESS WHERE WORK WAS DONE GALLONS RLNAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED16(R) <br /> aREAssTRAP FACILITY <br /> PLEA H NGLUDE ST.REETA DIRECTION STREET NAME AND CITY CHEMICAL <br /> city Sia <br /> city <br /> UO 11,n/ 4 Thi- GUS Ls ov w, CRY. <br /> y 0 g >oa� gilt <br /> City <br /> 9dz Gt/�-T Liv 0&"4-,o cit a� <br /> � .. • <br /> / C S 302 y3 GrJ, n 60y c, <br /> ty <br /> �71g city <br /> �A P�/U Lo - — Com;; c,tv <br /> r a U u <br /> Con/ C s S • Cl <br /> cit <br /> w <br /> cit ! dvv <br /> c � <br /> Page of <br /> EHO 42-04 <br /> 12127/13 <br /> SEPTAGE CLEANERS REPORT <br />