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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .....I 1868 East Hazelton Avenue, StoCI(ton, CA 95205-6232 Return this form by the <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd 12t" of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: / � � //J 7 0 1,I11EVA.� <br /> Company Address: /3. 2� ` Report for the <br /> ,� _ stn th of: �yeara <br /> Street Address City Signature: <br /> Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY GALLONS NAME OF TREATMENT <br /> 2S /, PUMPED LL�REASETRAP, FACILITY <br /> �� �`/�j� C CHEMICAL <br /> VV <br /> � ✓- Cit f� <br /> city 1 J � <br /> Fr,'L I1/ L; <br /> Cit >( <br /> Gni NG✓D �i�l ' G Cq <br /> cit <br /> /t e = City <br /> City <br /> Cit <br /> Cityaw <br /> �( <br /> I^ <br /> VCit / <br /> 7G L rn <br /> /�►/ :1City <br /> 5lly / <br /> 7 Zt/ cit <br /> J t Cit I f <br /> / v <br /> Cit ------------ <br /> EHD 42-04 Page <br /> 12/27/13 - - <br /> SEPTAGE CLEANERS REPORT <br />