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■i i0llllll <br /> SAN JOAQUIN COUNTY <br /> X013ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> •SUN '1 <br /> 600 East Main Street, Stockton, CA 95202-3029 12th of each month <br /> Telephone:(209) 468--3420 Fax.(209) 464-0138 Web;www.sjgov.orglehd <br /> _ F 4 <br /> SEPTAGE CLEANERS REPORT ti <br /> Company Name: r Z- Report for e of: year SCJ <br /> Company Address: 1- Signature: , <br /> Street Address C Ky Zip Code <br /> _ ti <br /> ti All information submitted must be com fete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R1 RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE IMCLUDE STREET N, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> a <br /> z <br /> 0 <br /> w 'A(we' S;71r� Y' �l '. .:J� C� <br /> V j <br /> L '- <br /> �J CK <br /> Cfty <br /> ity <br /> C <br /> city <br /> Clt <br /> C� <br /> G� <br /> city <br /> City <br /> city <br /> city <br /> 0 <br /> city <br /> N <br /> 1�> <br /> Cit o <br /> C i< <br /> C� <br /> EHO 42-04 SEPTAGE CLEANERS REPORT <br /> 1OW07 <br />