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ca` SAN JOAQUIN COUNTY <br /> z' ;•� <br /> "`• ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> r;<«� `r� Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12th of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: Report for the month of• <br /> �� •� Yearo2pl��~ <br /> Street Address Signature: �� A�� ,� <br /> City Zip Code � <br /> All information submitted must be com tete accurate, and le ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> , STREET NAME AND CITY PUMPED GREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION <br /> C FACILITY <br /> CHEMICAL <br /> fir �i/' ✓ Cit <br /> city. <br /> '�. D Cit ii �� <br /> S cit / <br /> o? d ci 1 <br /> 4VI'Vr Ci/2 city1 ( /SU -------------- <br /> 0 <br /> C ityJ <br /> s w � Cit <br /> /V,se.'4Cci� R®- pit 1 <br /> Uv �c 1 <br /> cit i l <br /> Cit <br /> 5 ,2 1-11"C140 cit <br /> Cityi I <br /> cit � 1 <br /> E H D 42-04 <br /> Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />