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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623212tH of each month <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www,sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: i✓ 'r'i r t1 �1 Report for the month of: ��A(1A'Jgear,_;-(,�_� <br /> Company Address: _0 t ) %�,�'�i( q - C L,� <br /> Street Address ''� ��� aC I • ��' Signature: <br /> Cit � <br /> Y 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 <br /> _ PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED (G) GREASE TRAP FACILITY <br /> C CHEMICAL <br /> ! 1 c1tv 6 <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Citi p <br /> CityF, �jj FNS <br /> Cit <br /> cit <br /> cit <br /> Cit <br /> Cit <br /> r <br /> at <br /> EIiD 42.04 <br /> 10/4/07 SEPTAGE CLEANERS REPORT <br />