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SAN JOAQUIN COUNTY � � <br /> Return this form by the <br /> ENVIRONMENTAL HEALTH DEPARTMENT to <br /> :k! =: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 2014 12 of each month <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org Ihd <br /> SEPTAGE CLEANER'S REPORT NTAEHEALT <br /> `SERVICES ' <br /> Company Name: e Report fo the month of: _s! Year a� <br /> Company Address: P .O . -4 q931 soun 14 Signature 4A' <br /> Street 7ddress City Zi ode <br /> All information submitted must be complete, accurate, and legible Zip <br /> (R) RESIDENTIAL <br /> DATE NAME OF BUSINESS OR ONS NAME OF TREATMENT <br /> ADDRESS WHERE WORK WAS DONE GAL IPED (G) GREASE TRAP FACILITY <br /> PUMPED PROPERTY OWNER PUI C CHEMICAL <br /> r <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY <br /> C <br /> E &alCfTejjmikuyR <br /> 13 0 C <br /> Cit <br /> Cit <br /> Cit <br /> CII <br /> Cit <br /> CII <br /> CII <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 /> 10/4/07 <br />