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• apR41>t <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> `'rfitaa �* Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sigov.org/ehd 12t" of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: A, <br /> Report for the mgnth of: <br /> Company Address: �j '� _ _ year, <br /> Street Address `ty �� ? Signature: <br /> City Zip Code <br /> All information submitted must be Com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R)//0 4) <br /> RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY ----� NAME OF TREAT <br /> PUMPED GREASE TRAP <br /> C CHEMICAL FACILITY <br /> 7 , Cit — <br /> �x v <br /> SLI/ Cit / 1( <br /> city- L/ <br /> /l Cit / <br /> City1 1 <br /> AVId S� z v v <br /> Cit' ,� Z <br /> cit <br /> ------------ <br /> Citya OU1� <br /> 0 /71 city A . t <br /> Cit � <br /> cit <br /> Cit <br /> r ��Sr Gds, e Cit Jr / <br /> City i <br /> ; r <br /> Cit / r / 7/"6. i <br /> l <br /> Cit <br /> EHD 42-04 Page Of - <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />