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• 1012-111 <br /> �tul�r <br /> 12-111 ,'FA . <br /> SAN JOAQUIN COUNTY <br /> % r _ ENVIRONMENTAL}-HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone:(209)468-3420 Fax: w <br /> (209)464-0138 Web:ww.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: Report for the month of: Year. <br /> �� <br /> Street Address <br /> Zip Code Signature: <br /> City <br /> All information submitted must be comlate accurate and le Ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY PUMPED GREASE TRA NAME OF TREATMENT <br /> _ l ,�7 C CHEMICAL FACILITlY <br /> V �' C/4"' <br /> City /I 4(1L) <br /> Cit <br /> fJ _ /ylS 3 a (7 -v dl �� el <br /> � <br /> � 9� <br /> ClW <br /> I&Q0 S ��,Z i Cit >i a <br /> i `� / dOlt-TR ICf/SA, cit 1 <br /> yvc2 2, � <br /> d1�U/Ll71 O/I/ Cit 1 <br /> F Cit <br /> F, �� <br /> me cit t f r Z <br /> Cit l/U <br /> P�•�e iE Cit t l <br /> .� Cit » <br /> B 4)L <br /> CitZA <br /> >� <br /> C It <br /> Ewo 42-04 <br /> Page of <br /> 12/27/13/13 <br /> SEPTAGE CLEANERS REPORT <br />