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Q�,Ruln. <br /> ur"w" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENTReturn this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12thof each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:Www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: il � �� � � �2� ` <br /> Report forth nth of: ear�� <br /> Company Address: <br /> Street Address - Signature: <br /> Clty Zip Code <br /> All information submitted must be Complete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER GREASE TRAp� NAME OF TREATMENT <br /> 04 <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED C CHEF FACILITY <br /> 4K41 <br /> Gt) Gl/1��/S�7�llC/,C <br /> _ city 9611d ��'� ✓� <br /> Zl1'Nc C itv <br /> XI <br /> LM city. <br /> at <br /> cit <br /> Ci <br /> Cit <br /> Cit <br /> city <br /> Ci <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/I3 SEPTAGE CLEANERS REPORT <br />