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'AMID <br /> • ? <br /> JUL 12 2017 <br /> z ' SAN JOAQUIN COUNTY <br /> a t <br /> ENVIRONMENTAL HEALTH DEPARTMENT :(,1VIRUfeMEN;qL H <br /> eturn this <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 DERMIT/aERM ,' to <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:. .form by the <br /> www.sjgov.org/ehd 512 of each month <br /> -------------- <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: rp, 1111/77) 42 <br /> 19-4 4 <br /> Company Address: .>, r' ./ X91? f�llG Report for the <br /> th of- ye <br /> ar <br /> Street Address Signature: �— <br /> All information submitted must be com tete accurate anliele ible Zip Code �' <br /> DATE NAME OF BUSINESS OR '-- <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY GALLONS �R) RESIDENTIAL <br /> PUMPED Gee Fs neo NAME OF TREATMENT <br /> ra�� �� CHEMICAL FACILITY <br /> ��� n ci ��97ff2�J G- ,SZC <br /> sU0F�tJVC ���. <br /> !i9'Jll�i1y9%D <br /> 5 �NNrG'ui my Cit <br /> 4 <br /> city sz L) <br /> ------------- <br /> -------------- <br /> o2v �j./,'J '� ��?z �S�U FSS � at . J •�OJc� ; , � / <br /> Let, <br /> ------------- <br /> cIt /I � 5 r� �� <br /> Ci <br /> Cit I( <br /> � �vpJi � _.r / � ,_ % i�/1/Orl- /� SCS S✓� v�' 7 <br /> Cityjgjg"Pjli <br /> Ci <br /> 0ZUl��Lv,o; /�v za/("6 <br /> Cit <br /> cit <br /> cit l� <br /> Cit <br /> EHD 42-04 <br /> 12/27/13 Page of <br /> SEPTAGE CLEANERS REPORT <br />