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mPCF- <br /> I <br /> z. ti SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL h -,Return this form by the <br /> ° 1868 East Hazelton Avenue Stockton, CA 95205-6232 PERMIT/SERV <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd `' 'c12tt� of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: Report for the moi th of: �✓t/U9�1 year <br /> ,_/jj"'� � _ <br /> Street Address city Zip Code Signature; %I/ <br /> All information submitted must'be complete, accurate, and le Ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS <br /> PUMPED PROPERTY OWNER (R) _RESIDENTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED ) oREASETRAPj FACILITY <br /> / U h CHEMICAL <br /> city <br /> L&- a � �= <br /> as Cit Vis'©d r i <br /> i6 <br /> /� city:,/ <br /> •04-eA lv i6d x . !/'��� �/ (/ cit L. �� r l <br /> %0%E Cr SGS a dS7 ud iit �J/ Cit I <br /> SCity <br /> Cit <br /> u ( J <br /> Cit i �CiVc� <br /> / moi vST9A r' n� l f D�l/✓d�71-4 -W-kd�Sim <br /> City <br /> ,� Cit i 1 f <br /> a4/0 liU�S ui9f� Cit l <br /> �uW� SUS '�4nl <br /> City <br /> F F Cit l l t l <br /> / ;ZR -6)o i <br /> city >/ �, - <br /> . J 1 <br /> p -I D Gv / //' <br /> rvi9C�s RUD l,{J,,1;,7Lvv; <br /> Cit <br /> of r <br /> EHD 42-04 Page_ <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />