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SAN JOAQUIN COUNTY <br /> "- ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton CA 95205-6232 Return this form by the <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: J11IS6-er� Report for the th of: year <br /> /- <br /> StreetAddr s ��y / <br /> city Signature; <br /> Zip Code It I <br /> All information submitted must be com tete accurate and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED GREASE TRAP NAME OF TREATMENT <br /> CHEMICAL <br /> FACILITY <br /> �^ Cit <br /> LF S/%L <br /> citJlJ <br /> (� �1� / ' Cit <br /> N• L ���T U ,� Ci <br /> km/cwc; - , /SSG' <br /> a LieGL'�T/yl /fl y <br /> Ci �� sad <br /> N 96/� FrJ�m��EE /J/Csil city <br /> /1-/( 2-7a <br /> cit ; <br /> /SO /CT <br /> CIN <br /> city <br /> Cit <br /> / WAlo�-- cit <br /> eo <br /> Cit /i -Vd <br /> GU%SOA/ <br /> EHD 42-04 <br /> Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />