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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,sJgovprg/ehd r <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 1 - Report for the month of: Year,� � <br /> Company AddresCi Irl r�-VSignature: , <br /> Street Address City Zip Code ' <br /> All Information submitted must be com late accurate and to ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R1 RESIDENTIAL NAME OF TREATMENT <br /> PUMPSD PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET A, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Cit <br /> city <br /> S � <br /> 4 <br /> cit <br /> cit <br /> City <br /> ".2 <br /> city <br /> cit vF^'�7, <br /> Cit <br /> city <br /> Cit <br /> ci <br /> cr <br /> cit <br /> city <br /> crr <br /> city <br /> c' <br /> cit <br /> Cit <br /> ,� n ' X06 � � " <br /> END 42-04 orii ,� SEPTAGE CLEANERS REPORT <br /> 10/41017 <br />