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In ° SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1._. 600 East Main Street, SIOCAton,CA 95202-3029 Ref or this form by the <br /> a Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd 2"'of each month <br /> (, <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: CC1 Yri Y j r) <br /> �. n box R'� 2 S Q -u Report for the month of: I CXLe year�� <br /> CompanyAddress; �J ������//���� y <br /> Slmel Add cM � Cg' ��c�et{�Signafure•� 1�ff,{Gf_ /�,Q��_ <br /> nv cAae <br /> All Information submitted must be com let* accurate, and le lots <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE 1R) RESIDExnA� <br /> = PIJtdPEO PROPERTY OWNER GALLONS <br /> F PLEASE INCLUDE STREET *, DIRECTION. STREET NPUMPED (G1 GREASE TRAP NAME OF TREATMENT <br /> AME AND CITY FACILITY <br /> CHEMICAL <br /> ) e(j1171)Y�„ 2Yrrl� 3 bQ �.{ <br /> � cn <br /> z <br /> c <br /> M <br /> w C <br /> C <br /> C <br /> C <br /> C <br /> Ct <br /> X) c <br /> n <br /> D NMENTAL HEA <br /> 0 <br />' c S <br /> n <br /> D <br /> v C <br /> C <br /> i <br /> C <br /> I <br /> Cs <br /> Cn <br /> EHO u-0* <br /> 101' 7 <br /> SEPTAGE CLEANERS REPORT <br />