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ojbo�' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd 12tH of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � c 2' ZI2� L <br /> l 0/9c"� <br /> �� Report for the month of: �2 <br /> Company Address: '11-5 year <br /> city��T% ,�, Signature: — l� G f� <br /> Street Address y <br /> Zip Code <br /> All information submitted must be Com lete 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 � N4MEO FACILITY PUMPED OREASETRAP > FACILITY <br /> / CHEMICAL <br /> Cit /� <br /> Cit / <br /> 7 Z <br /> City. �' 1 <br /> Cit <br /> cit <br /> - cit <br /> cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Ci <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> C It <br /> EHD 42-04 <br /> Page (: of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />