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RECE' SAN JOAQUIN COUNTY IV E <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> i 600 East Main Street, Stockton, CA 95202-3029 NOV 0 8 2013 12`h of each month <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT ENVIRONMENTAL HEALTH <br /> Company Name: ��i Report roheRmonth of: yearg 13 <br /> Company Address: O �l�c>/ j Signature: <br /> Street Address City Zip Code <br /> co All Information submitted must be complete, accurate, and legible <br /> M (i) RESIDENTIAL <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> KT© PUMPED PROPERTY OWNER PUMPED IG) CREASE TRAP FACILITY <br /> L PLEASE INCLUDE STREET 0, DIRECTION, STREET NAPE AND CITY C CNEWCAL <br /> 0 � n.Z �e cay <br /> H <br /> city <br /> city <br /> city <br /> C' <br /> city <br /> citv <br /> city <br /> C <br /> C' <br /> 0 <br /> z <br /> 3 <br /> city z5i <br /> I <br /> cityo <br /> 0 <br /> m <br /> city <br /> 0 <br /> cv <br /> co <br /> C1 <br /> I C' <br /> �:= o <br /> l <br /> cityz <br /> IT <br /> citya <br /> L7 <br /> fl C <br /> ity <br /> ISI <br /> lU C1:1 EHD 42-04 SEPTAGE CLEA�iERS REPORT a; <br /> i.I <br /> 10/4107 <br /> ■ ■ 0 0 0 <br />