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` SAN JOAQUIN COUNTY <br /> ENAROMIENITAL HEALTH DEPART161ENT <br /> 9868 East Hazelton Avenue, Stockton, CA 95245-6232 Return this form by the <br /> r tsti�`b Telephone:(209)468-3420 Fax: (209)4640938 Web:WWw.sjgDV.Drglehd 12 of each month <br /> SEP ' GE CLEAKER'S REPORT <br /> Company Name. <br /> Report for lzth <br /> Company Address: <br /> J eof. �� year <br /> strrlhdar�ss c%y Signature: <br /> A11 Information submitted must be coat tete, accurate, and le Ibie Zip Code <br /> DATE NAME OF BUSINESS OR <br /> PUMPED F ROPER y OWNER ADDRESS WHERE WORK WAS DONE f GALLONS (R) RESIEEMAt <br /> 7x� PLC-ASE I{{CLU DE STREET A, DIRECTION, STREET NAME AND CITY PUMPED (G) GREASETRAP NA6iEOFTREATMENT <br /> (C) CHERSICAL FACIIJTY <br /> l l 76 <br /> Cri <br /> cir, v� L <br /> C-. c" T SCS c) c <br /> ci <br /> cNi, 62.G c5 0 l <br /> Ll <br /> Cit <br /> 1 � <br /> cir o <br /> 0 <br /> Cil° <br /> Cit <br /> c <br /> C� b <br /> Ci <br /> C <br /> a <br /> Page of_L <br /> EJiD 42-04 <br /> 12J27I13 a <br /> a <br /> SEPTAGE CLEANERS REPORT <br /> 0%%%%m <br />