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Q.,gulty <br /> Lr SAN JOAQUIN COUNTY <br /> " r ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> +Its : Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �y / fir ry <br /> Report for;th nth of: <br /> Company Address: ,�.�,j( year.`'' <br /> StreetAddress Cit Signature: U �i/ <br /> y 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 GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED GREASE TRAP' NAME TREATMENT <br /> FACILITY <br /> CHEMICA <br /> EYIAi W b/TIl /J✓ /�t/� cl ��c°�C,!L <br /> %y Cit <br /> City <br /> L cit <br /> ��/l " G>// I / ✓,�9�/� �� <br /> cit i r <br /> it l / <br /> S /U f1/S P1/C cit <br /> JOJ2IJ2, A6 Wi S cit i r <br /> Yn A / Ic Cit i <br /> Cit <br /> � �-� d �w _/.� Cit 1{ <br /> City L <br /> D>1 AFL cit 1/ — <br /> P <br /> Cit <br /> City <br /> i� <br /> � MAO' c?/V S&1,77-1 <br /> EHD 42-04 Page <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />