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�.. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> fl% <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: ' 1 Y106alt C C LAO Report for the month of: ? �^ year 20 <br /> 2 <br /> Company Address: P � 9;�3 Scon t4 k4e(D , C 4 y��� Signature: ('1 ( <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 <br /> + 'NAME AND CITY C CHEMICAL <br /> city <br /> Tex Y '/ <br /> `1 Can c� t CI L-/ �n ClA.b T i 7 5 P', TO w z' Pb�r <br /> ' `- )►2G i s` C i/�[� C lLdb Cit L1" 4 U V ^ To iJZ.i� ��-�K <br /> cit <br /> at <br /> cit <br /> cit <br /> cit <br /> 15 <br /> cit <br /> city EMIRONMENTAL <br /> city <br /> RMIT/SERVICES <br /> cit <br /> city <br /> cit <br /> cit <br /> city <br /> city <br /> cit <br /> city <br /> cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />