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+,3,;ti>iri;; •, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this forth by the <br /> 1868 East Hazelton Avenue, Stockton, CA 98206-6232 12ti' of each (month <br /> 7'elepfr®ere:(209)4683420 fax; (209) 464-0138 Web:www.s,/gov;prg/ehd I <br /> SEPTAQE CLEANER'S REPORT <br /> Company Name: E; �Cel r1,i�� � Cl � report for the month of: � yeat��C�_ <br /> Signature:," <br /> Company Address: <br /> Streel Addressi CHH Zip mods <br /> All lnformatlon oubmittod must bm com letp accurako and lerilble <br /> ( 1 <br /> DATE NAIVE OF qU&INi~S6 OR AbgRE68 WHERE WORKWAS DONE GALLONS R) RESIDENTIAL NAME OF TREATMd�•` 11 <br /> PUMPED PROPERTY OWNERPUMPED (0) GREASE TRAP PACII.ITY <br /> PLEASE INCLUDE STREET 0, DIRECTION, BTREF�r NAME AND CITY (C CHEMICAL <br /> 11 U7 110 ( fc�, r� VVi `� ) <br /> — ��_i r"l< <br /> err _ <br /> city <br /> City _ <br /> city <br /> Cir <br /> Clr <br /> CII <br /> Clt <br /> city ` <br /> Clry <br /> I <br /> c1ty " <br /> My <br /> ail <br /> city _ <br /> Clt _._ .. <br /> R.I. <br /> EN042-04 SEP?-AGE CLE'AIVERS REPORT <br /> ary+ro7 <br />