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' RECEIVED <br /> DEC 14 2017 <br /> SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH <br /> .lO�•A <br /> ENVIRONMENTAL HEALTH DEPARTMENTffi27thof <br /> this.form by the <br /> 1868'East Hazeltgn Avenue, Stockton, CA 95205-6232 each month <br /> Telephone:(208)468-3420 Fax:(209)464-0138 Web:,www.S]9Ov-or9lehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: v / C S'2e j0Zdj'A <br /> Report for them Vth of: c year <br /> �� <br /> Company Address: �/3. i`' ' <br /> Street Address City -�-- Zip Code Signature: <br /> All Information submitted must be com1131112t& accurate and le Ible <br /> DATE NAM OPE BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL. NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED aRE 81TR"N FACILITY <br /> PLEASE INCLUDE STREET S DIRECTION STREET NAME AND CITY C CHEMICAL <br /> ' .. <br /> �1 f ' cl w �r� 1. <br /> %9�of�ELC h� Zed <br /> city <br /> '//7 1151M0 S ty. 0l �R 57,-)j <br /> v3S-Se A&Z-R7 Oty 0 <br /> J?�IiA) city $7J 1 , <br /> zr3 ' city <br /> city / . <br /> city <br /> g vODG9�Z / U Gf/ � ur�ni` 11v� cit <br /> 14 <br /> 3 Al Cl <br /> S'N 'n/� �iiA ' d �(.+ C'h/F�/C�djl��._�/ (���9v✓� cit <br /> crt <br /> 1 <br /> Page of <br /> EHO 42-04 <br /> 12127/13 <br /> SEPTAGE CLEANERS REPORT <br />