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z` SAN JOAQUIN COUNTY <br /> " f ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' 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: v� � ( r <br /> Company Address: ,�3 "' ,/ /�/f Report for the month of� year c?U/ <br /> Street Address cicy-`r"~ J Signature <br /> Zip Code - <br /> All information submitted must be Com tete 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 ( aREASETRA NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> City <br /> ,- <br /> �'���` �—� •, v W <br /> CityKip <br /> 'L <br /> n l <br /> 27?0 a,Cx CJJ cit % <br /> cit . <br /> cit <br /> cit <br /> City <br /> cit <br /> ------------- <br /> cit <br /> cit <br /> cit <br /> cit <br /> cit <br /> Cit <br /> cit <br /> EHD 42-04 <br /> Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />