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ar,4k f'1, <br /> cati SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> `'�raa�`�• Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12th of each month <br /> SEPTAGE CLEANER'S REPORT <br /> /�• <br /> Company Name: ,,�v � FY /,611 41S'ReLI � � � <br /> Company Address: �j "'�/�f3 ; Report for _fi nth of: r <br /> year v - <br /> Street Address ��l ? Signature• <br /> City Zip Code <br /> All information submitted must be Complete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS SRL�sID>" IAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY dT; NAMEO FACILITY PUMPED -� cREASErRAp� FACILITY <br /> ry �' )• C CHEMICAL <br /> Cit �L)� <br /> a L <br /> lJ T cit <br /> - <br /> City. / <br /> Cit <br /> / / 1 <br /> Cit <br /> Cit <br /> ll <br /> S. Sigr Cit <br /> Cit <br /> o' rl <br /> Cit <br /> Cit J <br /> CIV 7-d <br /> Cit <br /> �a i7 8 C Cit <br /> 14798 a fw...S�li`r.�c <br /> CitY916 <br /> `2b <br /> 1� 1/ <br /> o `2bL 2 Clty l <br /> leg City <br /> >j <br /> wr i 8 /Y� City <br /> 10a <br /> l 511 I <br /> EHD 42-04 Page Of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />