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abg SAN JOAQUIN COUNT( <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this fotvn by the <br /> r 1868 East Hazelton Avenge,Stockfons, CA 95205-6232 'f 20' of each month <br /> Telephone;(203)46&3420 Fax: (209)464-013B Web:%w -Sjgov.orglehd <br /> SEPT'AGE CLEANER'S REPORT �� <br /> Company Name: Report for Mtth,,of: u -''rear d <br /> Company Address: bo� Signature: <br /> Street Address ' <br /> Cite Zip Cade <br /> All information submitted must be complete, accurate and ie ibie <br /> DATE NAME OP BUSItIESS ORT ADDRESS Wfl ERE WORK WAS DONE GALLONS {R} RESfDEtMAL <br /> PUMPED PROPERTY OWNER (G) GREASE TRAP NAME OF TREAiT,7ENT <br /> PLEASE 111CLU E STREET 13 DIRECTION. STREET AFAE AND CJTY PUMPED C FAC[L" <br /> D Ge - S <br /> - 1� <br /> cr � <br /> U clt� Ga <br /> - r ( <br /> gee <br /> ca Cc !� <br /> CRYv l' cu ([ <br /> lc bo <br /> Lj�/city <br /> l <br /> z <br /> ca Q <br /> city <br /> 0 <br /> PAY1 <br /> Cfty ; <br /> city <br /> CR 1- <br /> Page of <br /> I— <br /> EHD 42-D4 <br /> 92129I13 SEPTAGE CLEANERS REPORT <br /> U <br /> N <br /> 11 1, 111 1/ Illi <br /> 11 1, 1, 11 11i <br />