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SAN JOAQUIN COUNTY Return this form by the <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> U� 12th of each month <br /> m 4_ 9868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> M1" , Telephone: (209)468-3424 Fax:(209)464-0138 Web:www.sjgov.orglehd <br /> Ld <br /> SEPTAGE CLEANERS REPORT <br /> Company fume: �2 Report for the month of: >cyear 200 <br /> ,� 5-5 Signature: <br /> Company Address: lD �16pry city Zip Code <br /> Street Address <br /> All Information submitted must be complete, accurate and legible (R) RE31NNTIAL NAME OF TREATMENT <br /> GALLONS <br /> DATE NAME OF BUSINES S OR ADDRESS INHERE WORKWAS DOME PUMPED (G) GREASE:TRAP FACILITY <br /> PUMPED PROPERTY OWNER PLEASE INCLUDE STREET 9, DIRECTION, STREET NAME AND CITY C CHEMtCAI <br /> ctt <br /> MY <br /> C <br /> Ci <br /> Cft <br /> at �, <br /> ct <br /> 0 <br /> z <br /> city Z�E <br /> Q <br /> co C <br /> (Yl m <br /> 00 <br /> M cito <br /> LD I� <br /> LD <br /> M Cil <br /> CD o <br /> CV cam+ <br /> Ci 1 <br /> rr; <br /> OD city <br /> �T <br /> rt <br /> �y Ci <br /> Cv 1 <br /> ritv <br /> — <br /> m <br /> 04 ofty <br /> v � <br /> SEPTAGE CLFANERS REPORT a <br /> CD EHD 42-04 <br /> ]014!07 <br />■ ■ ■ ■ ■ <br /> 0 ■ ■ ■ ■ <br />