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S <br /> ,RECEIVED <br /> MAR 10 2017 <br /> aF�R EWIRO W ENTAL HEALTHSAN JOAQUIN COUNTY <br /> PERMIT/SERVICE ENVIRONMENTAL HEALTH DEPARTMENT Return this tom by the <br /> 1868 East Haze(ton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov_orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: V Report for the month of: year,',)jC)j- <br /> Company Address: Signature: <br /> Street Address City Zip Cade <br /> All information submitted must be complete, accurate, and legible <br /> { DATE NAME OF BUSINESS OR ADDRESS WHERE WO RK WAS DONE GALLONS (R) RESIDENTIAL KAME OF TREATMENT <br /> PUMPED PROPERTY OWNER <br /> PUMPED (G} GREASETRAP FACILITY <br /> PLEASE INCLUDE STRErT p DIRECTION, STREET NA-FIE AND CITY C} GHEitICAi <br /> city <br /> I <br /> ITY <br /> C <br /> city <br /> Ci <br /> Lc� <br /> citym <br /> 0 <br /> Cit <br /> 0 <br /> z <br /> City :fEE <br /> Q <br /> Gil' o <br /> N <br /> city <br /> r� <br /> Ci o <br /> CI <br /> 0 <br /> Ci Ly <br /> a <br /> C ity <br /> 0tv <br /> a <br /> Ci[ <br /> Page.-of <br /> :■ SEPTAGE CLEANERS REPORT <br />