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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 12th of each month <br /> Telephone: 209 468-3420 Fax: 209 464-0138 Web:www.sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: n I/7O iC )cb't L�( �� Report for the month of: 6C. �Y year y ( <br /> Company Address: P, o . 8 k ct-2-3 say �C� > C �� �� q j' Signature: <br /> Street Address City Zip Code U <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 /> cit <br /> cit <br /> ca <br /> c' <br /> 2015 <br /> ar A.- -W <br /> cityERVICES <br /> city <br /> cit <br /> Cit <br /> cit <br /> cit <br /> Cit <br /> city <br /> city <br /> city <br /> cit <br /> Cit <br /> i <br /> f <br /> Cif <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />