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ECEIVED RN JOAQUtN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT n' <br /> APR 1 6 2015 =Re-turn form by the.. 1868 East Hazelton Avenue,Stockton, CA 95205-6232 Nti�,,_ :,_3�P Telephone;(209.)468-3420 Fax;(209)464-0138sl�:www.sjgov.org/ehd month <br /> o <br /> �:F.pR.. <br /> —+ ENVIRONMENTAL 10 jj SEPTAGE CLEANER'S REPORT <br /> Company ITISERVI f1�l IYl t �,. <br /> �_ �� Report for the month of: �A—D-C k years t A, <br /> �. Company Address: ,����>� _ <br /> o Street Address I city Signature: <br /> �—l—4+=.� f 6?1 � �'• <br /> rn <br /> All information submitted must be ca �Code <br /> m IQte, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS INHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> o NAME OF TREATMENT a <br /> PLEASE INCLUDE STREET f♦, DIRECTION, STREET NAME AND CITY PUMPED (GI GREASE <br /> FACILITY <br /> �QA��� U6..' f '`•-� C CHEMICAL <br /> C L- R c man"fe -- , <br /> <D0 city <br /> Cit reg. <br /> con wc <br /> C1, 00 <br /> Liq <br /> rII I. � <br /> ( I fad �f. 11`x'!`z" - ci h � j r <br /> � vdCit <br /> it f1 ` �C( wxr1{ tit <br /> ' c L Imo' i l} <br /> { <br /> city ` f <br /> I i�z C WM�Fcity <br /> I <br /> VA <br /> Ci t •G4 TM <br /> t Cf L <br /> EHD 42-04 n <br /> 10!4/07 7r <br /> SEPTAGE CLEANERS REPORT <br /> w <br /> C <br /> N <br />