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�r,R�tt!y <br /> z< 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 12tn of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: JJ �Addre;��W <br /> Report fort m th of: G year <br /> Strcity Signature: l <br /> Zip Code <br /> All information submitted must be complete, accurate and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS � -RES TIAL <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY eREasETRAP NAME OF TREATMENT <br /> PUMPED FACILITY <br /> C CHEMICAL <br /> Cl l/C D cit . C��L�� <br /> � I <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> ------------ <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> EHD 42-04 <br /> Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />