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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.sjgov,prg/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: CbIj!1„-1 4� ��� �. � � ���,�_ Report for the month year L> � <br /> Company Address: �� ��' ,_ j:Li n X Q oZ: 15 CIO Rakr� C1 � 3 Signature: <br /> Sheet Address City zlp 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 NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> �' d ?h1�. = t1C ocd C 4' 7 u-, 350 R 76 w% �C� <br /> city <br /> cit <br /> Cit <br /> cit <br /> city <br /> Cit <br /> c1t <br /> Ott <br /> cit <br /> city <br /> Cit <br /> Cit <br /> Cit pC �'t1F <br /> ci <br /> citycity <br /> city cit <br /> • 2ft <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> foi4ro7 <br />