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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 REPORT <br /> Company Name: f_��,� t n n, ; jun It A 1� Report for the month of: year i <br /> s � <br /> Company Address: ��, : r3_G C� :.� p n Q�{jC� Signature:' <br /> Street Address City Zi�pf de <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS �R1 RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED lG) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> G' � � C) t � i � •- s <br /> Q <br /> Cit .n <br /> Cit <br /> Cit 'AUG 1 I <br /> Cit <br /> City <br /> FERMITiSFPvtr:,, <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 1014107 <br />