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ur SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 12''of each month <br /> a Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: C Report for them hof: year <br /> Company Address: Signature: <br /> Street Address city Tip Code <br /> Co All Information submitted must be complete, accurate, and legible <br /> IDATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAlfiE OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GRE/ASETRAP FACILITY <br /> PLEASE INCLUDE STREET $, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> 117 I <br /> 0O f city <br /> city <br /> c <br /> c' <br /> CRY <br /> city <br /> CRY <br /> City <br /> c' <br /> city H GE I <br /> 0 <br /> c <br /> Q <br /> m <br /> city � <br /> city <br /> ENVIR MENTAL HEALTH <br /> 'C4 <br /> o <br /> 0c. <br /> o ; <br /> LY LC <br /> city <br /> <= a <br /> (L a' <br /> f'7 <br /> city cn <br /> GJ <br /> l9 <br /> city <br /> F— <br /> F) city <br /> CU >_ <br /> EHD 42-04 <br /> 1014107 SEPTAGE CLEANERS REPORT <br /> Wa <br />■ ■ ■ ■ ■ <br /> ■%V <br />