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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 121h of each month <br /> .;r Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:www.sjgovprg/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � [� J� j 6 1 i yj Report for the month of: ear <br /> Company Address: 0, t��O X Cfi" 3 'sap Mn-i -�, (4'4(3 Signature: <br /> Street Address City Zip 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 (GI GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> city <br /> Cit <br /> city <br /> cit <br /> Cit <br /> Cit <br /> city rTT <br /> 16 <br /> cityO <br /> VIRON � <br /> cit <br /> Cit ' <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> Cit <br /> cit <br /> Cit <br /> Cit <br /> E 14107 4 �� Yl VA 6- SEPTAGE CLEANERS REPORT <br />