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RECEIVE[,. <br /> 1 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 0 3 Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 Z013 12'h of each month <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:Www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT VIRONMENTAL FfFAI , <br /> Company Name: <br /> PERMIP/SERA</►rE <br /> Company Address: <br /> Report for the th of: year�O 3 <br /> � 5 <br /> etAdd Signature: <br /> *St�r—e <br /> C4 Zip Code <br /> All Information submitted must be complete, accurate and le Ible <br /> Li DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE (R) RESIDENTIAL <br /> I`' PUMPED GALLONS NAME OF TREATMENT <br /> PROPERTY OWNER <br /> PUMPED <br /> PLEASE INCLUDE STREET i, DIRECTION, (G) GREASE TRAP <br /> STREET NAME AND CITY FACILITY <br /> C <br /> J' CNEIRCAL <br /> 7 <br /> Cdy <br /> I- <br /> city <br /> C• <br /> C <br /> C- <br /> C' <br /> C' <br /> C• <br /> C r� <br /> 0 <br /> z <br /> C rn <br /> C• m <br /> 0 <br /> city <br /> O C-1 <br /> L <br /> v c. a <br /> uJ o <br /> f'7 <br /> citya� <br /> m � <br /> M <br /> tri EHD 42-04 > <br /> j� 10/4/07 <br /> (� SEPTAGE CLEANERS REPORT <br /> i <br /> r <br />■W_i <br /> ■ ■ ■ ■ <br />