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SAN JOAQUIN COUNTY <br /> EwiRDNMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 12'j`of each month <br /> Telephone:(209) 460-3420 Fax:(209)464-0136 Web:vnnnv,sfgov-ofglehd <br /> w � - <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 4 '/ Report for the ma of: U year <br /> Company Address: d - Y l-e. L <br /> Signature: <br /> �� <br /> Street Address City Tip Code <br /> All information Submitted must be'com tate, accurate, and legible <br /> CATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RIsIDEATAI. NAME OF TREATMENT <br /> JMPED PROPERTY OWNER PUMPED (0) GREASETRAP FACPi1TY <br /> PLEASE INCLUDE STREET A. DIRECTION, STREET NAME AND CITY C C}{Q� <br /> �l <br /> city <br /> W <br /> � G <br /> <=I <br /> 3 <br /> W C- <br /> H <br /> co <br /> <.I <br /> city <br /> co <br /> W City <br /> f` <br /> I <br /> city <br /> cityr <br /> Ci <br /> Vi-- <br /> city <br /> City DEC 09 2015 <br /> o <br /> z <br /> G <br /> �IVrMl AL HEAL I R Q <br /> � T <br /> m c' PMPT/SE-?ACES <br /> 0 <br /> L0 cityo <br /> v - <br /> OJ Ln <br /> m <br /> m o <br /> N c" <br /> City <br /> C <br /> m V <br /> N UtyD <br /> m <br /> city <br /> CD <br /> N <br /> � N <br /> EHD 42-04 <br /> �p 1014107 - SEPTAGE CLEA,4ERS REPORT <br /> L <br />