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anqu t'y, <br /> zo SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12th of each month <br /> Company Name: SEPTAGE CLEANER'S REPORT <br /> , for <br /> Report t nth of: <br /> Company Address: �3 "'- <br /> Street Address Clty Zip Code� Signature: <br /> L� <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) REIDE IAL <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED GREASE NAMED "HENT <br /> CHEMICAL FACCILITYILITY <br /> Cit <br /> .5–l�v <br /> city- <br /> r�rS� <br /> ity <br /> 7"/'f �— <br /> o� G>J, / <br /> City <br /> C cit <br /> Cit <br /> Cit <br /> Cit <br /> CAld/b 7 9 <br /> cityi <br /> Cit i l <br /> l/ l Slln/ cit 1 r <br /> CS L <br /> �Ucity <br /> Cit <br /> Aoi citv 7 1)VO <br /> EHD 42-04 Page _Of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />