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a04K try, <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 65205-6232 Return this form by the <br /> �4t�Fait:`l Telephone:(209)468-3420 Fax:(209)464-0 j3B Web:m"vr.sjgov.orglehd 12 of each month <br /> SEP AGE CLEANER'S REPORT <br /> Company dame: <br /> Company Address*et <br /> Report for the nth of: yea <br /> Address 3�ignature• y <br /> rq zip <br /> Code <br /> Ail lnformatlon Submitted must be cont lete, accurate and Je ibJe � � l <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS tR� RESIDENTIAL <br /> PLEASE IMCLUD TREET D RECTION STREET FAE AHD cITV (CI CHEMICAL <br /> GREASETRAP NAME OF TREATMENT <br /> PUMPED FACILITY <br /> 0CHEMICAL <br /> TU cr <br /> Cit• a <br /> c' ' G fc <br /> m <br /> Cit, t t 4 rn <br /> 0 <br /> Lin <br /> (It <br /> Ci. c <br /> Cil � <br /> :o <br /> 0 <br /> C' cv <br /> an <br /> Cit <br /> Cit a' <br /> F— <br /> Cil - <br /> Page of <br /> EHD 42-04 <br /> 12127113 <br /> SEPTAGE CLEMJERS REPOP,T <br />