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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone;(209)468.3420 Fax: (209)464-0138 Web:www,sjgovprg/ehd <br /> SEPTAGE CLEANER'S REPORT _ <br /> (Company Name: C� C ( Report for the month of: year <br /> Company Address: Signature: <br /> Street Address city Zip Code <br /> A-11-Information submitted must be-complete accurate and la lb-lo— <br /> DATE NAME OF BUSINESS OR ADORF-88 WHERE WORK WAS DONE GALLONS (R) RE6IDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET 0. DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> city o` S' <br /> ML& <br /> -city- <br /> city <br /> r cit <br /> city <br /> City <br /> ci <br /> CR <br /> cit <br /> city16 <br /> Cit t r <br /> city <br /> CHY494, <br /> cit <br /> CI <br /> city <br /> My <br /> Cr <br /> cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> IW4/D7 <br />