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ptlf�y C I 9 E <br /> �. SAN JQAQUIN COUNTY <br /> MAY 6 ZO14 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> 'Fb <br /> RONMENTAL HEALTH SEPTAGE CLEANER'S REPORT <br /> PERMIT/SE <br /> Company Name: _ Report for the month of: year D/ <br /> Company Address: 1,11Z Signature: <br /> Street Address City Zip Coda <br /> F" All information submitted must be'com lets, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS Iw RFSIDENTtaL NAd1E OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP <br /> 7PLEASE INCLUDE STREET $, DIRECTION, STREET NAME AND CITY FACILITY <br /> C CHEMICAL <br /> r Grin <br /> city <br /> city <br /> C' <br /> city <br /> city <br /> city <br /> city <br /> cv <br /> r— <br /> city cly, <br /> _ o <br /> C z <br /> rn <br /> CRY <br /> Ci <br /> City C—f0 <br /> l C <br /> L� <br /> C <br /> cu <br /> �i <br /> C a <br /> Q — <br /> C' � <br /> Ci a� <br /> lD � <br /> lU -- <br /> � a, <br /> EHD 42-04 <br /> 10/4/07 SEPTAGE CLEAVERS REPORT <br /> ■ ■ ■ ■ ■ <br /> ■ ■ ■ ■ ■ <br />