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SAN JOAQUIN COUNTY <br /> -�- ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 116a &;.A, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ( o-m ) �kb /,, Report for the month of: ear. <br /> Company Address: P. 0 • 2)0-Y- 'Sax1 RC1�0 C - ��`t ignature: (3 n J AQ- G�rz-)� <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL REATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP A <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Ci <br /> city <br /> l Z <br /> citypF9 'IFN p� <br /> CityF9ViC"�G <br /> City <br /> city I <br /> city <br /> cit <br /> City <br /> city <br /> Cit <br /> City <br /> Ci <br /> citv <br /> Ci <br /> Ci <br /> c1tv <br /> Ci I <br /> City <br /> 10C <br /> pg2-Dq —1 �O 1/ ' 1 SEPTAGE CLEANERS REPORT <br /> ,n,O vI+V) o�- <br />