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C <br /> m <br /> D >�� t SAN JOAQUIN.COUNTY <br /> m � ENVIRONMENTAL HEALTH DEPARTMENT Return this farm by the <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 12`n of each month <br /> c <br /> Telephone:(209)468-3420 Fax; (209)464-0138 Web:www,sjgov.orgJehd <br /> SEPTAGE CLEANER'S REPORT <br /> I`1 t1 I i - Report far the month of: � 4� year <br /> Company Name; ----- <br /> Company Address: A Ci�14 S ' t s �`} �.�, . 5c�nature: At.l l>h <br /> Street Address City Zip Code <br /> i <br /> All information submitted must be Complete, accurate, and legible I <br /> (R) RESIDENTIAL <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER (G) GREASETRAP <br /> 1 PUMPED FACILITY <br /> I PLEASE INCLUDE STREET !l, DIR!_CTION, STREET NAME AND CITY C CHEMICAL. <br /> ( Y`4 {t t 1 -L— <br /> city <br /> 11 n {-� _�' Ci <br /> ci l rxr �{72c f'LL ri �; <br /> 1 s r.,4} -1 ;ri`atiter i,. at <br /> T ' ; Cilv 14 <br /> - ' <br /> t( C City P ( cs`�1' tJ ) f• �' I"�L` <br /> CD <br /> Ci { <br /> o I �_? L N",1), 4 f 4 Citi f✓ di ✓ J <br /> t� J 7 f _ <br /> ty <br /> 4 <br /> Ll'� u <br /> r Cit <br /> N k 6r rrs�� <br /> ' <br /> City �t 7 {. < i �✓� f C:t%��Kt,- r`'tS1l <br /> flet-CU-1 <br /> } j1q. i"fi i `rii t �c-x { i i (? ' Cit <br /> city <br /> Cir <br /> CV <br /> Cit <br /> 0 <br /> Cit <br /> a <br /> Gi <br /> m 1— <br /> b City <br /> m > <br /> rn -- <br /> m SEPTAGE CLEANERS REPORT <br /> d - EHD 42.04 <br /> 1014/07 <br /> 6 <br /> F <br />