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$ S � F <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT I ' - � Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 JUN 6 '' 12th of each month <br /> Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:www.sjgovr ,��IEfq 7A,_H <br /> SEPTAGE CLEANER'S REPORT <br /> PERUTCSERVIC SUFI <br /> i � � ��� <br /> Company Name: k, rylw l b1 Cir� C )LLL, Report for the month of: Uw year—,L-Q) 6,, <br /> Company Address: �. 1'�C� k ,-�� Ga-V) tq CC4er q LW1 03 Signature: 'kAaI c. 6�7 czc <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 (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> C11 Cj- <br /> C Cit <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> city <br /> city <br /> Cit <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> Cif <br /> Cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 1014107 <br />