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naulry, <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> `• 1868 East 11azeltOn Avenue, Stockton, CA 95205-6232 <br /> res Telephone:(209)468-3420 Fax:(209)464-0138 Web;www.sjgov.org/ehd <br /> this form by the <br /> w.sjgov.org/ehd 12t" of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ry <br /> �� ,fir <br /> Company Address: /� Report for t m nth of: !I <br /> /.�, �I e s year lJ <br /> Street Address J Signature: <br /> All information submitted must be Complete. accurate and legible Zip Code <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE <br /> PLEASE INCLUDE STREET # DIRECTION D STREET NAME AND CITY GALLONS (R� RESIDENTIAL <br /> PUMPEGREASE NAME OF TREATMENT <br /> / c ICAL FACILITY <br /> BU A1�TyYi o,,, A' cit � � ��Z <br /> 0 <br /> Cit <br /> city. <br /> �g City 21 <br /> -57 0 mod--. <br /> ,�T- 1-7Gig u� Cit <br /> /7 0 GI/ ; CTE&V-DEj <br /> a cit � ' ` <br /> oZ`77 Cit l/ : -/ OL' <br /> t( <br /> cit <br /> Cit vU <br /> cit -------------- <br /> Cit I <br /> �rL ; t <br /> Cit , <br /> Cit <br /> ci <br /> EHD 42-04 <br /> 12/27/13 - Page of -. <br /> SEPTAGE CLEANERS REPORT <br />