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MAY 0 6 2013 SAN JOAQUIN COUNTY Return this form b the <br /> ENVIRONMENTAL HEALTH DEPARTMENT y <br /> EN',MQ-1'+9IVENTALH 600 East Main Street, Stockton,CA 95202-3029 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.orgfehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the mont year c20 <br /> Company Address: lV 7y 3 Signature: <br /> Street Address Cay Zip Code <br /> co All Information submitted must be-complete, accurate, and legible <br /> em-, GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> m DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE (G) GREASE TRAP <br /> d ILITY <br /> PUMPED PROPERTY OWNER <br /> / PLEASE INCLUDE STREET f, DIRECTION, STREET NAME AND CITY PUMPED D Ci�AL FAC <br /> O ( , C <br /> ity <br /> ritv <br /> citv <br /> citv <br /> City <br /> ritv <br /> ritv <br /> citv <br /> city OC> <br /> 0 <br /> citv <br /> M <br /> 0 <br /> z <br /> I <br /> rav <br /> a <br /> city CV <br /> Lfl <br /> CRYcr <br /> M <br /> -city <br /> O <br /> Com! <br /> C!ty <br /> O o <br /> city <br /> Q <br /> PLT11115 <br /> ci <br /> a� <br /> city <br /> F-- <br /> I <br /> Lfl EIiD 42-04 SEPTAGE CLEAMERS REPORT U <br /> ' 10/4107 <br /> is � <br />%■■ ■ ■ <br /> 0 ■ ■ ■ ■ <br />