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• Qr,441?{ <br /> 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 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �� v� e ��.?. � <br /> Report for the th of., year �? <br /> Company Address: �-���"•�'�� 13 <br /> Street Address Clty `°� Signature: <br /> 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 GAftDR <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUNAME OF TREATMENT <br /> FACILITY <br /> Cit S'r2 _ <br /> �L U//D ���Ct �0�. ✓r/ pit l <br /> �/ / <br /> 1 / / �G`/� !�� <br /> City- <br /> ' cit / <br /> v! " Lin& �pSD 11i� <br /> .�71 /'. l <br /> Cit /� Il✓a 11 <br /> cit I 1I <br /> Cit <br /> i <br /> city 03 / <br /> ( /nf9' �i-(��• cit 4 Eel,- <br /> 2&1 <br /> ' City I?(1c/ 11 <br /> a7c�� � � lam ,� Cit <br /> ✓c � <br /> 9�a 0zow"O�! <br /> Cit <br /> EHD 42-04 Page 7' of . <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />