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SAN JOAQUIN COUNTY <br /> �� � <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> ' <br /> Telephone: (209) 468-3420 Fax: 209 464-0138 Web:www.sjgov.org n� 16 2015 <br /> SEPTAGE CLEANER'S REPORT ENVIRONME.NTALHEALTH <br /> Company Name: n 11' 6 Report 1ior'M9!WAI RE65: '" r <br /> Company Address: © � O Q 0- 1 Ra&Q1 Signature: <br /> Street Address City Zip Code Q(�� <br /> All information submitted must be complete, accurate, and legible <br /> (;W <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Ci[ <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Ci[ <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> Cit <br /> CSO-�1, <br /> 10/44/07 04 ©` \ p� PTAGE CLEANERS REPORT <br /> � Drl,�s � - <br />