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SAN JOAQUIN COUNTY <br /> V� _ ENVIRONMENTAL HEALTH QEPRftTMEIdT Return this form by the <br /> f; <br /> 60D East Main Street, Stockton,CA 95202-3029 12 h of each month <br /> Telephone:(209)458-3420 fax: (209)464-0138 Web:www.sjg8 .o g hd <br /> SEPTAGE CLEANER'S REPORT <br /> a Company Name: Report for the month of:f.4n-r-'I. � year <br /> Company Address: Signature: <br /> r� reet AdAress city Zip Code <br /> a <br /> All Informatlan submitted must be Gom late, accurstOr find legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DOME GALLOartS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTYOWNOR PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N. DIRECTION, STREET NAME AND CLTY G CHEMICAL <br /> Giny <br /> cily <br /> city <br /> 3 <br /> city <br /> CiLy <br /> City <br /> City <br /> city <br /> city <br /> city <br /> CRY <br /> city <br /> Q <br /> CRY <br /> cF <br /> Ci <br /> C" c; <br /> 7 <br /> a <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> i17f4l07 <br />