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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.org/ehd <br /> SEPTAGE CLEANER'S REPORTr <br /> _ --? � ALL <br /> Company Name: 1� Gl � Report for the month of: year � � <br /> Company Address: (> > C� �CL�1 ��l � ���`� Signature: <br /> Street Address City Zip Code �L4� <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 /> ccryfkqlr 8 'tk cit '_!—i' k r j''L t ` � 'T 0 Lt JQA- Pay <br /> cit <br /> cit <br /> cit <br /> cit <br /> city <br /> cit <br /> Cit <br /> 2015 <br /> city Pro.,,MEN <br /> /SER CES <br /> city <br /> at <br /> cit <br /> cit <br /> cit <br /> cit <br /> city <br /> cit <br /> cit <br /> cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />